AFRF Injury and Bereavement Assistance Application
Please fill out this form to request financial support due to injury or loss.
Applicant Information
Full Name
*
First Name
Last Name
Rank
*
Please Select
Firefighter
Driver Engineer
Lieutenant
Captain
Battalion Chief
Deputy Chief
Assistant Chief
Station Number
*
Shift
*
Please Select
A Shift
B Shift
C Shift
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Nature of Request
*
Please Select
Injury/Hospitalization
Bereavement
Type of Assistance Needed
*
Food Assistance (up to $200)
Lodging Assistance (up to $500)
Travel Assistance (up to $300)
Please note: Total assistance cannot exceed $1,000 and this is a one-time award.
Briefly describe your situation and how the assistance will be used (max 250 characters)
*
Supporting Documentation (such as a doctor's note, hospital record, or death certificate)
*
Upload a File
Drag and drop files here
Choose a file
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Supervisor Information
Supervisor Full Name
*
First Name
Last Name
Supervisor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Supervisor Email Address
*
example@example.com
I understand this is a one-time assistance award and confirm that all information provided is accurate and complete.
*
I agree
Submit Application
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