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*Required information.

Applicant Information

First Name of Person Needing Assistance: *
Last Name of Person Needing Assistance: *
Address: *
City: *
State: *
Zip Code: *
First Name of Person Requesting Assistance: *
Last Name of Person Requesting Assistance: *
Phone: *
Department: *
Station: *
Reason Assistance is Needed: *
Amount Requested or Type of Assistance Needed: *

This form must be completely filled out and submitted to be considered by the Assistance Commitee. The maximum allotted funds to be awarded in a calendar year is $500.00 per person or family.

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