Individual - Grant Application Form
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A. Applicant Information

Applicant Name 
 *
Address *
Phone *
Email *
Occupation  *
Position / Title *

If you are completing this form on behalf of someone else, please complete the following with your information:

Name 
Address
Phone
Email
Relationship to Applicant 

B. Grant Information

Amount Requested $
*
Describe your need or hardship that this funding will address
 *
If approved, describe how this grant would enhance your quality of life 
 *
If approved, briefly describe how this grant would fit our mission of supporting the law enforcement community 
 *

C. Financial Information

List your household’s gross annual income before taxes $
 *

List the value of any other assets of your household (home, stocks, retirement accounts)$ 

 *

List other organizations from whom you have requested funds 

 *

Have other funds been secured 

 *
Required

If yes, list the total amount $ 

Provide any comments or information that may help us asses your need 

C. References

List at least two references whom we may contact to verify your need:

List Reference #1 (Name, Relationship, Phone, and Email Here:   *
List Reference #2 (Name, Relationship, Phone, and Email Here:   *

D. Publication Consent

The James and Derek Hotsinpiller Memorial Foundation, Inc. (the “Foundation” “we” or “us”) is a non-profit organization that is funded primarily by donations from the public. In order to inspire our audience to support our charitable mission by donating money, volunteering, or advocating for our cause, the Foundation may wish to publicly share certain aspects of your organization’s story through its website, social media, or traditional media outlets in the event it awards a grant. If you provide your consent for us to share your story, the Foundation will discuss its publication plans with you prior to sharing. You may change your mind at any time and revoke your consent. If you inform us, we will not use your story in future communications. Please understand that the Foundation may not be able to withdraw images and stories already published.

Please check one of the following:

E. Acknowledgement

By signing below, you certify that, to the best of your knowledge, the information provided with this application is true and correct. You also acknowledge that Foundation may reach out to you for additional information to verify your need and/or ensure that the any grant furthers the Foundation’s charitable purpose. You understand that this application in no way obligates the Foundation to provide any grant, and the Foundation expressly reserves its right to deny your application. You understand the Foundation may require you to agree to certain conditions in connection with any grant to you.

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