Vigilant Watch, Inc. has created a charitable relief effort that will provide support to ourRegional first responder public safety officials (“PSO”), active, retired and their immediate families, whether in the line of duty or not, who have suffered a hardship based on an injury, illness, or catastrophic event which has created a financial or physical hardship. These instructions correspond to the Vigilant Watch, Inc. Application (“Application”) as listed below.

1. Applicant’s Name. Please insert the name of the individual completing the Application.

2. Relationship of Applicant to PSO. Please designate the relationship, if any, between the Applicant and the above-named PSO.

3. Address of Applicant. Please insert the mailing address of the Liason/Applicant. Vigilant Watch will direct all written communications to this address to the extent such concern the Applicant.

4. Applicant’s Home Phone Number and Work/Cell Phone Number. Please insert the appropriate phone numbers of the applicant.

5. Applicant’s email address

6. PSO/Recipient’s Name. Please insert the name of the active or retired member on whose behalf this Application is being completed. This line should be left blank if the Applicant is a PSO and is seeking monies in his or her own right.

7. Marital Status. Please insert whether the PSO/Recipient is married or single, divorced, or separated.

8. Job Status of PSO/Recipient. Please indicate whether the PSO is active or retired.

9. Department/Assignment. Please indicate the current assignment of the PSO, if applicable.

10. PSO/Recipient’s Address. Please insert the mailing address of the PSO/Recipient if it is different from the address stated in line item number 3. Vigilant Watch, Inc. will direct all written communications to this address to the extent as such concerns the PSO/Recipient.

11. PSO/Recipient’s Home Phone Number and Work/Cell Phone Number. Please insert the appropriate phone numbers of the PSO/Recipient.

12. PSO/Recipient’s email address

13. PSO/Recipient’s Dependents. Please list the names, ages and relationship of the PSO’s dependents, if any. Generally, a “dependent” means any of the following individuals over half of whose support for the calendar year in which the application is submitted was received from the PSO:

  • (a) A son or daughter of the PSO,
  • (b) A stepson or stepdaughter of the PSO,
  • (c) PSO’s spouse.

The term “dependent” does not include any individual who is not a citizen or national of the United States unless such individual is a resident of the United States. The preceding sentence shall not exclude from the definition of “dependent” any child of the taxpayer legally adopted by the PSO, if, for the taxable year of the PSO, the child has as his or her principal place of abode the home of the PSO and is a member of the PSO’s household and if the PSO is a citizen or national of the United States. An individual is not a member of the PSO’s household, if at any time during the taxable year of the PSO, the relationship between such individual and the PSO is in violation of local law.

**Under any and all circumstances, the above definition of “dependent” shall be interpreted so that itconforms with 26 U.S.C.A. 152 (2001), as such may be amended from time to time, and to the corresponding regulations.

14. Nature of PSO/Recipient’s Illness, Injury, Disease or Event. Please describe the nature of the illness, injury, disease or event affecting the PSO/Recipient.

15. Verification of Medical Condition or Catastrophic Event. In order to process your request for assistance, we require doctor’s verification of your stated condition(s). Please ask your treating physician(or related health care provider such as a clinical psychologist, chiropractor, etc.) to write a brief letterthat includes the following information:

  • Names of diagnosed condition(s)
  • Date of onset of the condition
  • Medical treatments and related treatments for your condition
  • How your condition impairs or disables your daily living
  • Prognosis for recovery (short-term and long-term)

We recognize that it is sometimes difficult to obtain such information from treating providers. Please do

the best you can to gather these details so that we can be in an ideal position to assist you.

16. Does the PSO/Recipient need money due to a financial issue stemmed from his/her catastrophic illness, injury or event?

17. How much money is needed?

18. How the Funds Will Be Used? Please list the intended use(s) of the Funds. Each and every use should relate to the PSO’s illness, injury or catastrophic event.

19. Other services or need. Specify needs or services such as building a wheel chair ramp, need of medical equipment, medical travel/transportation, supplies, materials, etc. (Must relate to the PSO’s illness, injury or event.)

20. Volunteer Help. Specify needs for volunteer help or aid such as meals, transportation to and from appointments, etc. Need must relate to PSO/Recipient’s illness, injury or disease.

21. Signature. Date. The applicant should sign his or her name and date the Application as of the date of its signature.

Vigilant Watch executive board will evaluate and provide a written response to each Application no later than thirty (30) calendar days after its submission to Vigilant Watch, Inc. To be considered by Vigilant Watch, all applications must be mailed to Vigilant Watch, PO Box 68264, Virginia Beach, Virginia 23471 and completed in accordance with the Application and these instructions. Any and all questions or concerns must be sent, via certified mail, return receipt requested, to Vigilant Watch, Inc. at the above-stated address. No more than (1) application in any way relating to, or concerning, a particular PSO/Recipient may be submitted to Vigilant Watch in any one year period.