Catastrophic Application

Catastrophic Assistance Application

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Is your application related to Hurricane Helene?(Required)

What Department do you work for?(Required)

What state do you work in?(Required)

Please refer back to your facility

We are unable to accept an online application. Please contact the Warden’s Office at your facility and tell them you would like to apply for Catastrophic Assistance through the Correctional Peace Officers Foundation.

Please refer back to your facility

We are unable to accept an online application. Please contact the Warden’s Office or HR Department at your facility and tell them you would like to apply for Catastrophic Assistance through the Correctional Peace Officers Foundation.

Hurricane Helene Assistance Information

Your catastrophic application cannot be processed online. Due to the large need created by Hurricane Helene, we are unable to accept applications online for catastrophic assistance. In our desire to help as many people as quickly as possible, please contact the Warden’s Office at your facility and tell them you would like to apply for Catastrophic Assistance through the Correctional Peace Officers Foundation. If you are an employee of the Federal Bureau of Prisons, please apply with your local union president. CPOF is unable to offer catastrophic assistance for loss of food, power loss or vehicle damage. Assistance is only available when related to your primary residence.

Employee Information

Personal Data and Contact Information is kept confidential

Application Date(Required)

MM slash DD slash YYYY

Employee Name(Required)

First Last

Social Security Number(Required)

What are the last 4 of your social security?(Required)

What is your EID number?

Date of Birth(Required)

MM slash DD slash YYYY

Home Address

Street Address City State ZIP Code

Phone(Required)

Email(Required)

Are you married?(Required)

Yes

Spouse Name(Required)

First Last

Spouse Occupation

Do you have children living in the home?(Required)

Yes

Children's Name and Ages (living in the home)(Required)

Please provide names and ages of all children living in the home to complete your application.

Job Information

Facility where you work(Required)

Facility State

Job Title(Required)

Superintendent(Required)

Local Union President's Name(Required)

Local Union #(Required)

Contact Phone #(Required)

Warden/Superintendent Name (Please specify their title)(Required)

Work Phone

Has the facility been informed of your situation?(Required)

Name and title of person informed(Required)

Start/Hire Date(Required)

Last Day of Work(Required)

Expected Return Date(Required)

Do you have time on the books?

How many hours?(Required)

Referring Person Information

Personal Data and Contact Information is kept confidential

Did somebody refer you or are you referring someone to CPOF for assistance?

Referring Person Name(Required)

First Last

Name of Person Completing Application(Required)

First Last

CPOF Member?

Facility

Job Title(Required)

Phone

Reason for Assistance

What do you need assistance with?(Required)

Medical

Bereavement

Natural Disaster/House Fire

Other

Please explain why you need financial assistance(Required)

Illness and/or injury – In cases of illness or injury, if extensive travel is involved in obtaining treatment and/or therapy for the Applicant, their spouse or dependent children, financial assistance may be provided to help with medical travel expenses incurred; or if the Applicant is suffering financial hardship due to expenses not covered by their health insurance, assistance may be provided to help with those expenses.

Required Supporting Documentation

A current statement from the treating physician which includes a projected return to work date. If the Applicat is requesting monetary assistance with expenses their health insurance doesn’t cover, a copy of their medical/hospital bill must also be submitted to support those expenses. In situations involving the Applicant’s spouse or dependent child who requires medical attention, we would need the same documentation as mentioned above, though the Medical Diagnosis and Prognosis would pertain to the spouse or child, not the applicant.

Please upload doctor's note (diagnosis/prognosis)

Drop files here or

Accepted file types: pdf, jpg, jpeg, gif, Max. file size: 20 MB, Max. files: 5.

Please upload out of pocket medical bills

Drop files here or

Accepted file types: pdf, jpg, jpeg, gif, Max. file size: 20 MB, Max. files: 5.

Bereavement

In bereavement situations, financial assistance is limited to the applicant, their spouse, or dependent children, if no insurance or other finances are available.

Who passed away?

Employee

Other

Name of Deceased if other than employee(Required)

Relation to Employee(Required)

Name of Beneficiary (if other than spouse or employee)

Relation to Employee

Date of death

MM slash DD slash YYYY

Cause of Death(Required)

Required Supporting Documentation:

Please attach a copy of contract between the funeral home and the applicant. *All other family members do not fall within the guidelines unless the applicant was responsible for said family members’ funeral expenses and a copy of the contract between the funeral home and the applicant is required.

Please upload a copy of the funeral contract signed with the applicant.

Drop files here or

Accepted file types: jpg, jpeg, gif, pdf, Max. file size: 20 MB, Max. files: 3.

Please explain why you need financial assistance(Required)

In situations involving fire, flood, hurricane, tornados, etc.; assistance may be provided if the Correctional Employee has been displaced from their home causing them severe financial hardship.

Have you received assistance from FEMA or Red Cross?

Yes

If YES: Please explain where you have received assistance and what type/amount of assistance you have received.(Required)

Required Supporting Documentation

Fire/Damage report or copy of homeowners/renters insurance claim.

Please upload a fire/damage report, or homeowners/renters claim

Drop files here or

Accepted file types: pdf, jpg, jpeg, gif, Max. file size: 30 MB, Max. files: 5.

Have you lost uniforms?

Yes

Pant Size

Shirt Size

Boot Size

Shirt Type

Polo

Button Up Utility

Polo Type

Short Sleeve

Long Sleeve

Button Up Utility Color

White

Gray

Button Up Utility Type

Short Sleeve

Long Sleeve