CPOF Fred Mann's Lucky Bag Application

COAST GUARD CHIEF PETTY OFFICERS FOUNDATION
FRED MANN’S FAMILY LUCKY BAG FUND APPLICATION

 

Applicant/Beneficiary Information

Name (First MI Last) *
Email Address *
Phone Number *
Mailing Address *
Beneficiary’s Name (if different from Applicant’s) (Last, First, MI):
Beneficiary’s complete mailing address (if different from Applicant’s):
Beneficiary’s email (if different from Applicant):
Beneficiary's Phone
Please provide a detailed reason for this request (loss of job, medical issue, etc.): *
How will the grant be used? *
Has the Beneficiary received a grant of financial assistance from other sources? *

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If yes, provide the name of source and list the support provided.
Additional Information or Applicant’s Comments / Questions

APPLICANT / BENEFICIARY Acknowledgement: 

By submitting this application requesting a grant from the Coast Guard Chief Petty Officers Foundation (CGCPOF), I hereby declare that the information contained in this application is accurate to the best of my knowledge and understand that any misstatement of fact may be grounds for denial of this request or recoupment of a grant. I expressly waive and hold harmless the CGCPOF and any representative who may be acting on behalf of the Foundation, from any and all claims that might arise as a result of this application. I understand that the CGCPOF is an independent private entity, and not part of the U.S. Government.

This application form is not subject to the Privacy Act (5 U.S.C. 552a). This form, with any attachments, will be kept on file by the CGCPOF President for a period of five (5) years. The CGCPOF Fund exists to help meet the Beneficiary’s basic needs, including but not limited to:

a. Housing/Lodging
b. Medical treatment including medicine/prescriptions
c. Food
d. Emergency Travel
e. Childcare/Respite
f. Funeral Expenses

Disbursements WILL NOT be considered for the following:

a. Credit card expenses
b. Legal expenses
c. Business debts
d. Late fees or irresponsible financial acts

Please note: Processing this request may take up to ten (10) business days. The Applicant will be contacted via e-mail regarding approval/disapproval of the request.

APPLICANT / BENEFICIARY Acknowledgement: *

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