APPLICATION TO COLORADO PROFESSIONAL FIRE FIGHTERS FOUNDATION FAILURE TO COMPLETE ALL BLANKS MAY RESULT IN DENIAL OF THE APPLICATION

Name:______________________________________________________________________________

Address:____________________________________________________________________________

Phone Number:___________________________

E-mail address:______________________________

Social Security Number of Applicant:___________________

Date of Tragedy:____________________

Marital Status: (Circle One ) Single Married Divorced Widowed Gross Family

Income Last Year:__________

Describe the tragedy for which you seek a grant (Attach additional sheets if needed)____________________________________________________________________________________________________________ ___________________________________________________________________________________

Describe any additional circumstances that aggravate the impact of the tragedy on you or your family (Attach additional sheets if needed) _______________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Describe how you will use any grant that is awarded (Attach additional sheets if needed) ___________________________________________________________________________________________________ ___________________________________________________________________________________
If awarded a grant, may the Foundation use your circumstances in its solicitation of funds from potential donors? __________

May we use your name(s)?____________________

If awarded a grant, do you consent to an investigation into the use of the funds?____________________

______________________________________ Signature

_____________________________________ Date

The purpose of the Foundation is to try to relieve some of the economic hardship caused by tragedies and natural disasters suffered by Colorado residents or others while in Colorado. The Foundation has limited funds and there are many people who may be deserving of grants. Not all requests can or will be funded. Decisions on funding will be made by the Board of Directors. The Board will consider the following factors in making its decisions: the event causing the harm must have occurred within 6 months of the application; the nature of the tragedy; the cause of the tragedy; the impact of the tragedy on the applicant or his/her family; the financial circumstances of the applicant and the intended use of any award. The Foundation reserves the right to investigate any information contained on this application in order to help make its decision about funding Mail to: Colorado Professional Fire Fighters Foundation 2342 Broadway Denver, CO 80205 opeiu #5 afl-cio