Beneficiary’s Name

Address

City

State

Zip

DOB

Phone

Email

If Married Spouse’s Name

Spouse’s Occupation

Applicant’s Name

Address

City

State

Zip

DOB

Phone

Parent

Grandparent

Grandchild of Firefighter

Advocate for Beneficiary

Firefighter’s Information Date of Retirement

What circumstances let you to request financial assistance?

Amount of financial assistance requested?

Payee

Amount

Amount

Amount

Are any of these bills partially or fully covered by insurance? If yes, please describe:

1.

2.

3.

Important notes about the application process:

• Please completely fill out this application.

• We may contact you for a brief phone interview after we have reviewed your application.

• The Retired Firefighters Association of Montgomery County, Maryland Inc (Association) is a Section

 501(c)(3) tax-exempt nonprofit corporation, and is subject to various legal requirements in awarding

 grants. All grants will be made in accordance with the Grantmaking Guidelines of the Association and

 applicable law and payments will be reported as required by law.

• Additional information and documentation may be required (1) in order to qualify for a grant, (2) to

 disburse funds, and/or (3) after a grant is made, to confirm that the grant funds were used for the

 intended purposes (e.g., receipts). The Association will determine in its sole discretion whether the

 documentation provided is sufficient.

• The Association seeks to support individuals who are eligible for assistance under the Association

 Grantmaking Guidelines. However, eligibility for a grant does not guaranty that a grant will be

 awarded. All grants will be made by the Association in its sole discretion.

• By signing this form, I acknowledge and agree that if a grant is awarded: (1) the grant funds must be used

 for the purposes described in this application, (2) any amounts not used for those purposes (or other

 purposes subsequently approved by the Association) must be returned to the Association, (3) it is my

 responsibility to report grants as required by law for federal and state income tax purposes.

Full Name/ Signature ( type your name)

Date