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

Applications must be filed within 12 month or less from date of injury.

Application For Assistance

Fields marked with an * are required

Date *

Injured Officer's Full Name *

Department *

Badge # *

Officer's Address *

Email *

Phone *

Person filling out application *

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

Description of Injury *

(Describe in detail the nature of the injury and cause of 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 officer returned to work? *

• Yes
• No

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 Officer's medical insurance cover all costs? *

• Yes
• No

Are you a military veteran? *

• Yes
• No

If you are a human seeing this field, please leave it empty.