Application for Grant
FALLEN PATRIOT FUND

Entire form must be completed (Applicant must be US resident)

Date:______________________

Name:_____________________           DOB:____________________

Address:___________________________________________________________

City:__________________   State:___________________      Zip:___________________________

Day Phone:__________________    Evening Phone:_____________________   Email Address:__________________________________

Applicants Highest Level of Education Completed:_______________________________________________


Please state the nature of your financial hardship and how the money will be spent if a grant is provided:  (you may attach additional information)

_______________________________________________________________________________________________

_______________________________________________________________________________________________


Military Life Insurance____ Amount $_______________ Beneficiaries_____________________________________________________________

Military VA Benefits____ Monthly Amount $______  SS Benefits____ Monthly Amount $__________

Other Benefits Available To Family: ___Life Insurance ___ Social Security  ___ Other

If Other Please Specify:______________________________________

NAME OF SOLDIER:________________________________________________

YOUR RELATION TO SOLDIER:__________________________________________________________

LIST OF CONTACT INFORMATION FOR OTHER FAMILY MEMBERS:

Name: Name: Name:
Address: Address: Address:
Phone: Phone: Phone:
Email: Email: Email:

Military Branch: ___Air Force ___ Army ___ Coast Guard ___ Marines ___ Navy

Rank:__________________________

EVENT OF LOSS: ______________________________________________________________________

Please attach death certificate or military notification of loss if submitting a request for a soldier killed in the line of duty

If you are applying based on serious injury, please state the date you were discharged from the military

and if you have not yet been discharged, the date you expect to be discharged __________________________________

 

IMPORTANT INFORMATION FOR INJURED SOLDIERS:
Due to military regulations, we can not award grants to soldiers who have not been discharged from the military.

You may apply for a grant at anytime but if you are still on active duty,

we would not be able to process your application until you are discharged from the military.
 

Please Mail the completed application to:

Fallen Patriot Fund
c/o Bank of America Private Bank

TX1-492-19-09

P.O. Box 832409
Dallas, TX 75283-2409.

Applications may also be faxed directly to 214-242-2160

 

The Fallen Patriot Fund of the Mark Cuban Foundation was Established to help families of U.S. military personnel who were killed or seriously injured during Operation Iraqi Freedom. Financial resources are vital to enhancing the sustainability of the family unit who has suffered a loss because their loved one sacrificed him/herself for freedom. Within that group, grant recipients will be selected in accordance with criteria established by The Mark Cuban Foundation. All proceeds will be disbursed.