Application for Financial Assistance

AGENCY & SUPERVISOR INFORMATION

Agency / Department Name*

Agency County*

Agency / Station Street Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Badge Number / Employee ID*

Volunteer responders: enter your member or state certification number.

Direct Supervisor / Department Chief / Volunteer Coordinator

Supervisor Full Name*

Supervisor Official Work Email*

Official agency address only — not Gmail, Yahoo, or personal email.

Supervisor Direct Cell*

May FROM contact your supervisor?*

Yes

Authorization: By submitting this form, you authorize FROM to contact your agency or supervisor solely to verify your employment as part of the assistance review process. All information is kept strictly confidential.

WHAT HAPPENS AFTER YOU SUBMIT

A FROM team member will review your intake within 3–5 business days.
If your request is approved to move forward, we will contact you by phone or email to discuss your need.
You will then receive the full financial assistance application with instructions for any supporting documentation required.
Your completed application will be reviewed by FROM staff and/or presented to the Board of Directors for final review and approval.

I certify that all information provided is true and accurate to the best of my knowledge. I understand this is an intake form only and does not guarantee assistance. I will respond promptly to any follow-up contact from FROM. I acknowledge that if FROM is unable to reach me, my request will be closed.

Applicant Signature*

Date*

God bless you and your continued service to Mississippi.

ELIGIBILITY & NATURE OF NEED

YOUR INFORMATION

AGENCY & SUPERVISOR INFORMATION

Direct Supervisor / Department Chief / Volunteer Coordinator

WHAT HAPPENS AFTER YOU SUBMIT

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Application for Financial Assistance

ELIGIBILITY & NATURE OF NEED

YOUR INFORMATION

AGENCY & SUPERVISOR INFORMATION

Direct Supervisor / Department Chief / Volunteer Coordinator

WHAT HAPPENS AFTER YOU SUBMIT

CERTIFICATION & CONSENT