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HomeMy WebLinkAboutFinancial_Assistance_Application_20200811.doc FINANCIAL ASSISTANCE APPLICATION Tax ID: 364519083 The mission of SLO LEAF is to provide immediate and temporary financial assistance to San Luis Obispo County law enforcement personnel and their immediate families, who are currently employed or honorably retired and who are experiencing a catastrophic financial need due to; serious injury, critical illness or at time of death. Instructions 1. Requesting employee should complete all sections of this form including signatures. 2. Email/mail application form, all pertinent copies of invoices, bills, receipts and credit card statements to SLO LEAF at the address below. IF APPROVED, PAYMENT WILL BE MADE DIRECTLY TO CREDITORS Employee Information (Please Print) Employee Name: Luca Benedetti Employee Agency: San Luis Obispo PD Requesting assistance for: ○ Self ▢ Immediate Family Member Name: Rick Scott Relationship:Employer Age:N/A Home Mailing Address: 1042 Walnut St. State: CA Zip: 93401 Mobile Phone: ( Work Phone: ( 805 ) 781 - 7256 Home Phone: ( Home Email: rscott@slocity.org Explain your request for funding (Attach paper if more room is needed) The community and Police Department of San Luis Obispo lost an amazing police officer in Luca Benedetti when he was tragically shot and killed in the line of duty on May 10, 2021. There is no department budget to fund expenses related to his death for either the department or his family. This request will help cover expenses for department members to witness his enrollment in the state police officer's memorial at $2680 and for his wife and kids to witness his enrollment in the national police officer's memorial at $2735 f or a total of $5415. Total amount requested on this application: $ $5415.00 Type of assistance requested: ▢ Direct (Bill pay to creditors) ▢ 501c(3) Fiduciary (For your fundraising activity) Do you plan to request additional funds? ▢ No ▢ Yes ▢ Unknown at this time I do hearby certify all the information to be correct and true. REQUESTING EMPLOYEE SIGNATURE: DATE: (Agency Use Only) D.A. Sheriff Chief of Police Dept.Head Rick Scott - Chief of Police 4/4/2022 Print Name Signature Date Revised 08-11-20/dj SLO LEAF P.O. Box 13126 San Luis Obispo, CA 93406 www.sloleaf.org Contact CJ Hunt with questions I 805.801.4616 I sloleaf@gmail.com