Name of Fallen Worker *

First Name

Last Name

Applicant Name *

Who is this filling out this form?

First Name

Last Name

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

Name of Beneficiary

To whom should we send funds?

First Name

Last Name

Beneficiary Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Permission to Use Image *

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

Yes

No

Disclosure and Agreement *

The funds disbursed by this grant are considered a gift and are not taxable as income. Grants are subject to fund availability. Fallen worker grants are available for work-related deaths only. 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

Confirm Death is Work-Related *

Fallen Worker Grants are open to transportation workers who have been killed in the line of duty. By checking this box you acknowledge that this incident was work-related.

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