APPLICATION FOR ASSISTANCE RUNNING 4 HEROES

NOMINATOR’S INFORMATION

NAME: ADDRESS: AGENCY: WORK #: CELL #: EMAIL:

BENEFICIARY’S INFORMATION

NAME: AGENCY: ADDRESS: CELL #: EMAIL: AGENCY: WORK #: AGENCY CONTACT: WORK #: WORK STATUS: FULL-DUTY: LIGHT-DUTY: ON LEAVE: RETIRED: OTHER: DESCRIPTION: APPROXIMATE RETURN TO DUTY DATE: NONE-COMPLETE DISABILITY:

SUMMARY OF INCIDENT / SITUATION

DATE OF INJURY: AT THE TIME OF INJURY, DUTY STATUS: ON: OFF: INVESTIGATING AGENCY: REPORT #:

Page 1 of 3 SUMMARY OF INCIDENT / SITUATION

Page 2 of 3 ASSISTANCE ELIGIBILITY CRITERIA

1. BENEFICIARY SHALL BE A UNITED STATES CITIZEN 2. BENEFICIARY SHALL MEET ONE OF THE FOLLOWING EMPLOYMENT CRITERIA: A. ACTIVE EMPLOYEE OF A PUBLIC SAFETY AGENCY TO INCLUDE, BUT NOT LIMITED TO: 1. POLICE DEPARTMENT 2. SHERIFF’S DEPARTMENT 3. FIRE DEPARTMENT 4. EMERGENCY MEDICAL SERVICES (EMS) 5. PAROLE OR PROBATION AGENCY 6. STATE CONSTABLE 7. CORRECTIONS DEPARTMENT 8. OTHER APPROVED AGENCY PER THE RUNNING 4 HEROES EXECUTIVE BOARD 3. BENEFICIARY MAY REQUEST ASSISTANCE UNDER THE FOLLOWING SITUATIONS A. ON-DUTY RELATED INJURY-TRAUMATIC OR DISABLING B. OTHER TRAUMATIC EVENT OR APPROVED CONDITION AS DEFINED BY THE RUNNING 4 HEROES EXECUTIVE BOARD

4. BENEFICIARY SHALL NOT BE UNDER INDICTMENT OR FACING CRIMINAL CHARGES FOR UNLAWFUL ACTIVITY WHICH RESULTED IN THE INJURY OR DISABILITY FOR CONSIDERATION

5. BENEFICIARY OR PERSONNEL REQUESTING THE ASSISTANCE FOR THE BENEFICIARY MUST PROVIDE BASIC INFORMATION PER APPLICATION FOR ASSISTANCE TO BE SUBMITTED FOR REVIEW AND APPROVAL BY THE RUNNING 4 HEROES EXECUTIVE BOARD

6. THE RUNNING 4 HEROES EXECUTIVE BOARD RESERVES THE SOLE RIGHT TO DETERMINE THE ELIGIBILITY OR APPROVAL OF A BENEFICIARY PER MAJORITY VOTE OF THE EXECUTIVE BOARD MEMBERS

7. THE RUNNING 4 HEROES EXECUTIVE BOARD RESERVES THE SOLE RIGHT TO DETERMINE THE ELIGIBILITY OR APPROVAL OF A BENEFICIARY PER MAJORITY VOTE OF THE EXECUTIVE BOARD MEMBERS

8. THE RUNNING 4 HEROES EXECUTIVE BOARD RESERVES THE SOLE RIGHT TO AMEND OR ALTER THE CRITERIA BASED UPON EVOLVING SITUATIONS OR STATUS AS NECESSARY

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