Request Assistance – Fauquier First Responders Foundation

Request Type

Is the person completing the form the same person who needs assistance?

Requester Full Name

First

Last

Requester Phone Number

Requester Email Address

Code Recipient Supervisor

Requester Relationship to the Recipient

Requester Preferred Contact Method (Optional)

Recipient Full Name

First

Last

Recipient Phone Number (Required if available)

Recipient Email Address (Optional)

Recipient City, State, and ZIP Code

Address Line 1

Address Line 2

City

State

Zip Code

Recipient Preferred Contact Method (Optional)

Is it safe to leave a voicemail or send a text message? (Optional)

Agency or Department Name

Role or Title

Employment Type

Supervisor or Agency Contact Name (Optional)

Verification Phone or Email (Optional)

Is the situation related to a line-of-duty incident?

Incident Date

Describe the incident

Describe the hardship

Type of Hardship

Urgency Level

Type of Assistance Needed

Estimated Total Amount Requested

Describe or break down the expenses

Supporting Documentation (PDF, JPG, PNG)

Drag & Drop Files, Choose Files to Upload

Has the recipient received assistance from other organizations or sources?

List other organizations or sources (Optional)

Consent and Acknowledgment (Required)

I certify that the information provided is true and accurate.
I authorize the Fauquier First Responders Foundation to contact the recipient and any agency or verification contacts listed.
I confirm that the recipient is aware of the request and agrees to be contacted.

Non-emergency Notice