APPLICATION FOR ASSISTANCE

Please be assured that all information provided on this application and attachments will be held in strict confidence and reviewed by Board members only. It is very important that the application is complete and provides as much information about the circumstance and need for assistance. This will help the Board during the decision-making process. Please be sure to attach any supporting documentation. Medical bills should be HIPPA Compliant. Any supporting documentation should be emailed to info@mariettapolicefoundation.org.

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Position / Title

Department

Number of Children/Dependents

Have you requested assistance before?

YES

If YES, please list date of previous request

Please list why you are requesting aid; what is your hardship? Please provide as much information as possible.

How has this hardship affected you, your family, your you’re your finances?

List any bills that you are requesting assistance. Please provide copies of all related bills by email to info@mariettapolicefoundation.org