RIPEA/William R. Murphy Foundation Request

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2023 Individual Grant Application (Click to Review Full Application before completing.)

Are you (the applicant) a current RIPEA member?* *

Member's Full Name *

Member's Email

Member's Address *

Member's Phone Number *

Are you completing this application for yourself or someone else? *

Myself

Someone else

*If you are completing this application for someone else, please enter your name, address and phone number here (Enter N/A, if not applicable): *

Member - Social Security Income. Enter monthly amount (Enter 0, if not applicable): *

Member's Spouse - Social Security Income. Enter monthly amount (Enter 0, if not applicable):

Member - PERF Income. Enter monthly amount (Enter 0, if not applicable): *

Member's Spouse - PERF Income. Enter monthly amount (Enter 0, if not applicable):

Member - Employment Income. Enter monthly amount (Enter 0, if not applicable): *

Member's Spouse - Employment Income. Enter monthly amount (Enter 0, if not applicable):

Member - Other Income. Enter monthly amount (Enter 0, if not applicable): *

Member's Spouse - Other Income. Enter monthly amount (Enter 0, if not applicable): *

Enter combined total monthly income for member and spouse (Cannot exceed $3,000): *

Amount of Grant Requested (Must be $1,000 or less): *

Describe purpose for which Grant will be used:
*

Will any part of this obligation be paid by insurance? *

Yes

If you answered yes to the question above, please enter the amount paid by insurance (enter N/A, if not applicable): *

Please provide a copy of the bill(s) for which the grant will be used. If submitting a credit card bill, please provide a list of the eligible expenses included on the bill(s).

Indicate below whether the documentation will be provided via email or mail:

Via Email attachment (ripea.murphyfoundation@gmail.com)

Via USPS (RIPEA/Murphy Foundation, 2415 Directors Row, Suite M, Indianapolis, IN 46241)

DIGITAL CONFIRMATION:
Your digital signature is a very important part of the electronic grant application process. For those not submitting paper grant requests, we require you to digitally “sign” the forms.

Digitally signing the grant request form is considered the same as signing a paper copy in legal terms. Only the signatory themselves must use their digital signature.

To digitally sign this grant application, just click the box below before submission:

I completed the above application and verify that all of the information provided is accurate.

Required

For the person who digitally signed the form, please type your name below: *

Submit

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