Application for Assistance

Texas commissioned peace officers suffering a life-altering line of duty injury, please fill out the following form to be reviewed by the POAF Southwest Region board for criteria requirements per POAF Southwest Region by-laws.

(All material is kept confidential)

(Please type or print legibly)

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Date *

Injured Officer's Full Name *

Department *

Badge # *

Officer's Address *

Email *

Phone *

Person filling our application *

(Officer’s supervisor, family member or injured officer)

Description of Injury *

(Describe in detail the nature of the injury and cause of the injury)

Was the officer hospitalized? *

• Yes
• No

If yes, how long? *

Will officer under-go rehabilitation? *

• Yes
• No

Number of days off work? To date *

Estimated future days off work *

Has the officer returned to work? *

• Yes
• No

costs? a long?

Light Duty? *

• Yes
• No

Description of Need *

(Describe in detail how this situation has affected the officer and his/her family and any unusual or extenuating circumstances that may contribute to his/her need for assistance. Please be as thorough as possible and you may use additional pages if needed.)

Will the officer require long term care? *

• Yes
• No

If yes, how long? *

Does the officer's medical insurance cover all costs? *

• Yes
• No

Are you a military veteran? *

• Yes
• No

Submit