EMS Help Fund Apply for Assistance This application will take some time to complete. To ensure you do not lose your work, please have the following information ready to fill in. -Financial reasons for application -Monthly Income -Pension Income -Government assistance -Alimony income -All bank accounts with values -All financial investments with values -Home mortgage or renter informationALSO, please ensure you are using one of the following browsers with recent updates for security and compatibility purposes (we do not recommend a mobile device if possible) -Firefox-Safari -Chrome -Edge-Internet Explorer is no longer supported Employee: * Officer Paramedic EMT Last Name * First Name * Middle Name or Initial * Appointment Date * Station Number Active Duty Yes No Rank Retired Date Veteran? * Yes No Phone * Cell Email Address * Marital Status * Single Married Divorced Domestic Partnership Family Name Relationship Age Name Relationship Age Name Relationship Age Name Relationship Age Emergency Contact Phone * Full Address * Reason for Assistance * Financial Medical Prescription Home Health Care Respite Care Reason for Requesting Assistance * Financial Obligations from above Amount Source Amount Source Amount Source Amount Source Primary Healthcare Coverage Supplemental Healthcare Coverage? Is Civil Action Planned or Pending Yes No Workers Compensation Yes No Workers Compensation Yes No Family Income Average monthly FDNY Salary Applicant Spouse/Domestic Partner Other income Other Income Pensions Monthly Pensions Monthly Pensions Monthly Pensions Monthly Pensions Monthly Government Assistance Unemployment Assets/Portfolio Type Checking Savings Bank Amount Type Checking Savings Bank Amount Type Checking Savings Bank Amount 457 Deferred Comp Plan Market Value 401k Plan Market Value IRA Market Value Investments CD Money Market Mutual Funds Stocks Bonds Total from Above Accounts * Investments Brokerage Retirement Accounts Total from Above Accounts Any Rental Income? Yes No Value Other Real Estate owned/investments List here with values Residence Homeowner Yes No Monthly Mortgage Mortgage Balance Date Purchased Type of Home Single 2-Family Multi-Family Townhouse Condo Co-Op Purchase Price Held by Lien Holder Renter Yes No Monthly Rent Outstanding Debt Credit Card Personal Loan Medical Dental Car Lease Car Loan Equity Line of Credit Equity Loan Student Loan Outstanding Debt Total Value from Above Other Obligations Have you ever received assistance from EMS FDNY Help Fund before? * Yes No I authorize the directors and employees of the EMS Fund to receive and review all information included in this application and any additional information provided by me to be confidentially shared between the Honor Emergency Fund and the EMS Help Fund with the understanding that that any and all information requested by and submitted to the EMS Help Fund will be used to verify my identity and other relevant information for purpose of determining whether I and/or my household is eligible or continues to be eligible for assistance or benefits from the EMS Help Fund. Submit reCAPTCHA * Last Name
