CARING FOR POSTAL FAMILIES APPLICATION FOR RELIEF FUNDS


Check One:

         
__________Section 1. POSTAL EMPLOYEE
              Career employee on the rolls in a pay status and in good standing with 
              the USPS, in the 334,349, and 329 Zip Code and has exhausted (or nearly
              exhausted) their annual and sick leave upon submitting an application  
              and is suffering from a debilitating disease, illness or injury and 
              IS NOT EXPECTED TO RETURN TO DUTY. (JOB RELATED INJURIES OR ILLNESS ARE EXCLUDED) 

__________Section 2. A DEPENDENT SPOUSE, CHILD OR PARENT OF A POSTAL EMPLOYEE
              The dependent is suffering from a debilitating disease, illness, or injury
              and it requires the employee to take time off from work to attend to their
              needs and the Postal employee has exhausted their annual leave (or nearly exhausted) 

EMPLOYEE’S NAME        ______________________________________

SOCIAL SECURITY NUMBER ______________________________________

ADDRESS                ______________________________________

                       ______________________________________

POSTAL POSITION:       ______________________________________

IMMEDIATE SUPERVISOR   ______________________________________

NAME and TELEPHONE # OF RELATIVE OR PERSON TO CONTACT FOR ADDITIONAL
INFORMATION            ______________________________________

FOR SECTION 1: YOU ALSO MUST SUBMIT MEDICAL DOCUMENTATION WITH A DIAGNOSIS AND
PROGNOSIS STATING WHETHER YOU ARE ANTICIPATED TO RETURN TO DUTY

FOR SECTION2: YOU MUST SUBMIT CURRENT MEDICAL DOCUMENTATION WITH A DIAGNOSIS AND
PROGNOSIS STATING THE EMPLOYEE IS NEEDED TO CAR FOR THE IMMEDIATE FAMILY MEMBER

EMPLOYEE’S SIGNATURE   ______________________________________

DATE:                  ______________________________________

PRINTED NAME, phone number, AND RELATIONSHIP IF OTHER THAN EMPLOYEE MAKING REQUEST
                                                                                                                   ______________________________________

MAIL TO : CARING FOR POSTAL FAMILIES INC
          P O BOX 18853
	  WEST PALM BEACH, FL   33416-8853