Temporary Assistance or Memorial Fund Application

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CTF routinely establishes temporary Assistance and Memorial funds for transportation workers who have been injured or killed on the job. Donations made to these funds are not tax deductible. CTF will match donations made to such a fund dollar-for-dollar up to $7500, when the injury or death is work-related. From time to time we may also establish a fund for a transportation worker who has been injured or killed in a non-work-related incident or to assist with mental health matters related to a job-related incident. All funds received to a specific assistance or memorial fund are transmitted to the beneficiary directly. CTF does not charge an administrative fee. Once approved, assistance and memorial accounts will remain open until no donations have been received for six (6) consecutive months. Additional information about establishing a new assistance or memorial account can be found here>>

Name of Injured or Fallen Worker

First Name

Last Name

Employer Name

Please tell us the name of the injured or fallen worker's employer.

Applicant Name

Who is this filling out this form?

First Name

Last Name

Applicant Email

Applicant Phone Number

What is the best number to reach you?

(###)

###

####

Supervisor Name

If you are not the employee's supervisor, please provide the supervisor's name.

First Name

Last Name

Supervisor Email

Please provide the email of the worker's supervisor, if other than applicant.

Name of Beneficiary

To whom should we send funds?

First Name

Last Name

Beneficiary Address

Where should we send the check(s)?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permission to Use Image

May we use an image of the injured or fallen worker on our website, social media and in CTF communications?

Yes

No

Disclosure and Agreement

I understand that any amounts received by CTF and designated for the requested assistance or memorial fund are held by CTF exclusively as an agent of the fund beneficiary(ies), that CTF retains no discretion over the use of such funds and that amounts received by the fund do not constitute tax deductible contributions to CTF. I will include the statement that amounts received by the fund are not charitable contributions in all written and oral statements relating to the fund. I understand that this account cannot be established without the approval of the employee's supervisor. In the case of Caltrans, this requires a Deputy District Director or Division Chief approval. For other organizations, a similar level of authorization is required.

I agree

Was the incident work-related?

CTF may establish assistance and memorial accounts for transportation workers who have been injured or killed in the line of duty. From time to time we may also establish accounts for workers who have experienced a non-work related injury or fatality. Please confirm whether the injury or death was work-related.

Yes, the worker was injured or killed in a work-related incident.

No, this account is for a non-work related injury or death. (Not eligible for matching funds).

This is a mental health assistance account for a work-related event. (Not eligible for matching funds).

This is a fire related assistance account for a non-work related event (Not eligible for matching funds).

Circumstances

Please provide a brief description of the circumstances of the injury or death.