UFLAC FIREFIGHTERS BENEVOLENT FUND RELIEF APPLICATION

United Firefighters of Los Angeles City, IAFF Local 112

UFLAC Firefighters Benevolent Fund Relief Application

UFLAC Firefighters Benevolent Fund Relief Application

FIREFIGHTER PERSONAL INFORMATION

Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Department Address
Department Address
City
State/Province
Zip/Postal

Supervisor Name
Supervisor Name
First
Last

INCIDENT DESCRIPTION

Please select the qualifying incident below

MAILING INFORMATION

Mailing address you wish to receive these funds at
Mailing address you wish to receive these funds at
City
State/Province
Zip/Postal