2017 Shop with a Cop Application

2017 Shop with a Cop Application


Application should be completed and returned to the address below. Do not leave any spaces blank. Missing or omitted information will cause your application to be DENIED. A telephone number must accompany this form. Eligible children are age 0 to 12 years of age. If you have received two consecutive years of assistance your application will not be considered. On the shopping day, your child must be present in order to shop. Child must live in HendricksCounty. You must enclose a copy of a utility bill to show proof of residency in Hendricks County. (Use back of Form for Additional Children)

Child’s Name: ______Age: ______Grade: ______

Child’s Name: ______Age: ______Grade: ______

Child’s Name: ______Age: ______Grade: ______

Name of Responsible Party: ______

Relationship to Child: (Circle One) Guardian Parent

Address: ______Email: ______

City: ______Zip Code: ______

Telephone Number: ______Best time to call: ______

(You must provide a valid telephone number)

Total Combined Annual Household Income: (Check One)

______$0 to $10,000.00

______$10,000.00 to $15,000.00

______$15,000.00 to $20,000.00

______$20,000.00 to $25,000.00

______$25,000.00 to $30,000.00

______Over $30,000.00

Number of persons in household: ______

Have you recently been laid off? (Circle One) Yes NoIf Yes, when? ______

Name of School: ______

Have you applied for assistance from any other organizations? (Circle One) Yes or No?

If so, name of organization______

Have you ever received Assistance from Shop w a Cop? (Circle One) Yes or No? What year?______

*By completion and your signature on this application, you give the F.O.P. the right to make inquiries with other organizations about assistance you are receiving.

Signature: ______Date: ______

Applications must be post marked on or before November 23, 2017.

Form MUST be completed and mailed to:*FOR FOP OFFICE USE ONLY*

Shop With A Cop ProgramApproved Y/N Called______

F.O.P. Lodge #132Denied: Y/N

PO Box 132Reason: ______

Plainfield, IN 46168______

Fraternal Order of Police Lodge #132

Shop with a Cop Program

Regulations regarding Shop with a Cop

Please print and retain this page for your information.

The program is intended to help as many families in Hendricks County as possible. Only applicants with one year or no assistance will be considered for 2017.

If you are a resident of Hendricks County 2-1-1 is a United Way Funded service that connects people with providers of essential human services. Dial 2-1-1 or 317.926.4357 or go to connect2help.org for a listing of assistance programs available in your area.

1.Child must be present and accompanied by a parent or guardian on the shopping date. Purchases cannot be made for children who are not present. NO EXCEPTIONS. Children who miss their scheduled date will not be rescheduled.

2.Each Child shall be a resident of HendricksCounty.Enclose a utility bill

or property tax statement to show proof of residency. You must be the Parent, or Legal Guardian of the child.

3.Merchandise CAN NOT be returned or exchanged. A list will be provided to the service desk for all items purchased by the Lodge on your shopping date.

Make sure all children try on clothes and shoes prior to purchasing the items. Anyone attempting to return merchandise will be reported to the Lodge and will be ineligible to participate in future assistance programs.

4.Each child will be allowed to spend a specific amount and will not be allowed to go over that amount.

5.Due to the number of children we take shopping, your shopping time with an Officer will be limited to 30 minutes. It’s a good idea to have a specific list of items your child needs to have with you.

6.An approval letter will be emailed to the address listed on this application (or mailed via USPS if no email address is provided. The letter must be presented on your shopping date along with a photo ID of the parent or guardian.