Name: *
Social Security Number *
Address: *
City: *
State: *
Zip: *
Email Address: *
Phone: *
Name of Company/Institution
Describe the Situation *
To assist the Trustees, please describe in detail the situation resulting in your request for assistance and indicate how the situation relates to the purposes of this Fund. In your narrative description, please include the names of individuals involved in your situation and their roles in the events you have documented. Also, please specify the times and places for the events you have described, and include as attachments any supporting documentation(press reports, memos, etc.). Your narrative also should contain an explanation of the financial ramifications of your situation and explain why you are asking for the amount of aid you are requesting in this application.
Legal Counsel *
If you are presently represented by legal counsel, please provide counsel’s name and contact information. In addition, please ask your counsel to provide the Trustees with a brief overview of the legal issues in the case and the status of the case to date.
References *
Please include the names, relationship and contact information of three people from your local community who are familiar with your current situation. We recommend that these people not be members of your immediate family
Additional Information
If you would like to email additional supporting documentation as an attachment, please send to
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