Request for Benefits Form
The person(s) completing this form acknowledge that their request has met the criteria set forth by Get Behind
The Badge guidelines to receive financial benefits or assistance with the fundraising efforts to provide those
financial benefits. Criteria for receiving benefits can be found on our website or by contacting the Executive
Director at 614-212-7526. Completion of this form is for request purposes only and does not constitute that
benefits will be provided to the requestor or the beneficiary. Restrictions apply and requirements are subject to
change without notice. All requests must be approved by the Executive Board and/or the Benefits Committee.
This form can be e-mailed to our Benefits Committee at getbehindthebadge@gmail.com .
Please provide a brief narrative for request:
Beneficiary Information: Requestor Information:
(Check if same as beneficiary)
Name:
Name:
Address:
Address:
Phone No.:
Phone No.:
E-Mail:
E-mail:
SSN#:
Reason for
Request:
LODD Line of Duty Death
Relationship To
Beneficiary:
Family Member
CI Critical Injury
Department Representative
Hardship (explain in narrative)
Legal Counsel
Date of
Occurrence:
Other (explain in narrative)
Signature:
Signature
________________________________________________________________
(official use only below this line)
Request fit criteria:
Yes
No
Event Approved:
Yes
No
Approved By:
Board
Benefits Committee
Authorizing Signature:
Funds Disbursement:
Name:
Expenses Amount:
Title:
Beneficiary Amount:
Signature:
GBTB Amount:
Other: