CSPFF

Information of Intended Recipient of Funds *

Must be completed by a CSP employee, on behalf of a CSP employee. Or, a CSP retiree, on behalf of a CSP retiree.

First Name

Last Name

Phone *

(###)

###

####

Mailing address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is the recipients role within CSP? *

Trooper

Port of Entry

Communications Officer

Professional Staff

Retiree

Is the recipient an active or retired member of the Colorado State Patrol Association and in good standing? (This is not Colorado Wins) *

Yes

No

Don't Know

If the recipient is a retired member, when did they retire?

MM

DD

YYYY

If you are a third party requestor, does the recipient know you are completing this hardship application on their behalf?

Yes

No

Has the intended recipient ever previously applied for hardship? *

Yes

No

Don't Know

I have read and agree to the CSPFF's Hardship Fund Guidelines *

Yes

No