Retired Firefighters Association of Montgomery County, Maryland Inc.
Retired Firefighters Association of Montgomery County, Maryland Inc.
Please see the Associations’ Grantmaking Guidelines for information about eligibility and the grantmaking process
Beneficiary’s Name
Address
City
State
Phone
Zip
DOB
If Married Spouse’s Name
Spouse’s Occupation
Applicant’s Name
Address
City
State
Phone
Zip
DOB
How are you related to the beneficiary?
Firefighter’s Information Date of Retirement
What circumstances let you to request financial assistance?
1.
Amount of financial assistance requested?
Payee
Purpose
Amount
2.
Payee
Purpose
Amount
3.
Payee
Purpose
Amount
Total Amount of Financial Assistance Requested:
Are any of these bills partially or fully covered by insurance? If yes, please describe:
Dependents (if applicable)
1.
Relationship
Age
2.
Relationship
Age
3.
Relationship
Age
Have you applied for and/or received other financial assistance related to this request? If so, when and from what source? (Include GoFundMe, FundtheFirst, or other fundraiser link if applicable)
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
By typing your name above I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement.