Request for Assistance

Fill out this form to request assistance for a financial hardship being suffered by a DEAFNA member, employee or TFO.

Your Name *

First

Last

Email *

Mobile No. *

Cell phone number

Title/Office *

Your title and/or office name

DEAFNA member, DEA employee or TFO on whose behalf this request is being made: *

Active Duty or Retired?

Active Duty
Retired

Is he/she a current member of DEAFNA?

If Active Duty, does this request have the support of Division Management?

If Yes, please provide name, title and cell number for Division Management contact:

Is there a GoFundMe or other fund-raising effort underway for this party?

If yes, please provide the link or describe the effort:

Please provide a brief statement regarding the nature of the situation that gives rise to this request and a fair estimate of the financial hardship being suffered by the member, employee or TFO. All information provided is considered confidential and is used solely for the purpose of making a determination regarding assistance. (NOTE: IF THIS REQUEST INVOLVES A MEDICAL OR SENSITIVE MATTER THAT YOU WOULD PREFER TO DISCUSS PRIVATELY, PLEASE MAKE THAT KNOWN HERE AND A FOUNDATION REPRESENTATIVE WILL CONTACT YOU DIRECTLY.)

Email address of the President of the DEAFNA Foundation:

President@AFNAFoundation.org

Request for Assistance

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