The Disabled Police Officers of America - Application for Financial Assistance

Disabled Police Officers of America

Application For Financial Assistance

Personal Information:

Name: (Last,First,M.I)
Mailing Address:
City:
State:
Zip Code:
Home Phone (with area code):
Email Address:
Department Retired From:
Date Of Retirement:
Was Retirement Optional or Disability?

Employer Information:

Current Employer:
Employer Address:
City,State,Zip:
Employer Phone #:

Income Information:

Monthly Household Income From All Sources ($):
Number of People in Household:
Monthly Expenses ($):

Assistance Information:

Requesting assistance for (list items and associated dollar amounts, e.g. prescriptions, utility bill, car repair bill ):
DPOA Financial Assistance awards are based on financial need, please provide summary of hardship situation:

Total Amount Requested ($):

Payment Distribution Information:

List the names and addresses of the companies to whom payments are to be issued. Additional information should be put in the "extra" field.

#1

Company Name/Contact Name: (Last,First,M.I)
Mailing Address:
City:
State:
Zip Code:
Phone Number (with area code):
Account Number :
Amount Requested:

Company Name/Contact Name: (Last,First,M.I)
Mailing Address:
City:
State:
Zip Code:
Phone Number (with area code):
Account Number :
Amount Requested:

Company Name/Contact Name: (Last,First,M.I)
Mailing Address:
City:
State:
Zip Code:
Phone Number (with area code):
Account Number :
Amount Requested:

List any extra information here:

TO DISABLED POLICE OFFICERS OF AMERICA, INC. FINANCIAL ASSISTANCE APPLICANTS:

Proof of police retirement, disability or optionally retired, and a photo, must be provided with this application.

Mail supporting documentation to:
Disabled Police Officers of America
222 Government Avenue, Suite C.
Niceville, Florida 32578

· Applicants must provide with this application a copy of any unpaid bills/statements or invoices for which the financial assistance awards are to be distributed to.

· All monies awarded will be paid directly to creditor/service provider etc.

· DPOA Financial Assistance awards are not intended to be a re-occurring award, but rather for a sudden financial emergency and are limited to $1,000.00 award per annum.

· DPOA Financial Assistance awards are subject to the availability of funds. Any unused portion of an award will be returned to the DPOA.

· If selected and given an award, the recipient agrees to allow the use of his/her name, photo, department and brief bio to be printed in upcoming editions of the DPOA Newsletter, as well as inclusion in the DPOA web site and any other future fundraising literature or scripts. No personal data, such as address or telephone number will be released, without the prior approval of the award recipient.

· Awards to applicants will be made by the DPOA Awards Selection Committee, and will be made on a non-discriminatory basis, with financial need being the prime consideration.

All statements made on this application are subject to verification. Any invalid assertions will result in the application being removed from consideration.