Survivor Fund Request For Monetary Assistance Request for Inclusion on the Wall of the Fallen Form

Survivor Fund Request For Monetary Assistance
Request for Inclusion on the Wall of the Fallen Form

International Towing and Recovery Hall of Fame and Museum

3315 Broad Street
Chattanooga, TN 37408
Phone: 423-267-3132
Fax: 423-267-0867

*****No Fees Required*****

**Detailed circumstances surrounding death should be attached to this form on a separate sheet**

**Death MUST have occurred while the deceased was on the job**

This Section For Survivor Fund Only

Name of Person That Funds Will Be Distributed To:
Physical Address:
City:

State:

Zip:

Country:
Phone:

Fax:
Email:
*Distribution must be made to someone 18 or older.
Any person other than spouse or dependent children must provide proof of dependency on the deceased.:
List any other facts (if any) you believe ITRHFM should be aware of:

Documents attached:

Death Certificate

State Association information
Copy of Marriage Certificate

Obituary
Copies of birth certificates for dependent children

Police Report of incident
Newspaper article(s)

Name and phone number of police department
Other
All pertinent documents should be attached to this form for submission. A copy of the police report should be submitted with this request if available.

I certify that the above information is true and correct to the best of my knowledge at the time of submission. I understand that review by ITRHFM is confidential, and that its decision is final. I also understand that any award is discretionary, and that meeting the eligibility criteria does not guarantee an award. Should an award be made to me, I agree in advance to allow ITRHFM to list and publish the donation to me and my family.
Signature of Submitter:

Date:

Privacy Information: Submitting information is strictly voluntary. By doing so, you are giving the ITRHFM your permission to use the information for the intended purpose. If you do not want to give the ITRHFM Permission to use your information, simply do not provide it. However, not providing certain information may result in the ITRHFM 's inability to provide you with the services you desire.
© 2007 International Towing and Recovery Hall of Fame and Museum, Inc