Online Applicaiton

• STUDENT/APPLICANT INFORMATION

• Name*
  First Middle Last
• Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Home Phone*
• Email*
  Enter Email Confirm Email
• Are you currently active duty law enforcement?
  • Yes
  • No
• Are you retired law enforcement?
  • Yes
  • No
• Are you currently a family member of an active or retired law enforcement member?*
  • Yes
  • No
• If yes, please indicate your relationship:
  • Spouse
  • Child
  • Other Dependent
• Please select affiliated agency:*
  ICECustoms and Border ProtectionFEMASecret ServiceCoast GuardOther
• If Other, please specify:
• Which hardship will this grant support?*
  Active Duty Law Enforcement InjuryActive Duty Law Enforcement DeathActive Duty Law Enforcement Medical ConditionActive Duty Law Enforcement Family Member (Death, Serious Injury or Medical Condition)Victim of Fire or Natural DisasterActive Duty Law Enforcement Unpaid Leave of AbsenceOther
• If Other, please provide a brief description of the circumstances, (including date event occurred):
• Please indicate the type of financial assistance you are requesting, by checking any or all boxes below that may apply:*
  • General Purpose Grant
  • Gift Card (please note, gift cards may vary based on availability)
  • Household Necessities (groceries, household items, hygiene products, childcare products, etc)
  • All of the Above
  • Other
• If Other, please describe what would best support your needs:
• If requesting household necessities, please indicate/describe which items will best support your needs.

• If your grant request is approved, please indicate to whom the grant should be distributed to:

• Name
  First Last
• Address
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