Juan Gomez Legacy Fund

Recipient Name, Address, Phone Number & Email Address

Recipient Place of Employment

Individual Presenting the Nominations Name, Phone Number & Email Address

Relationship to Nominee

*If not, It was reported to you by (Name & Contact Information)

Please Indicate the Life Changing Incident: (check applicable)

Loss of life of an individual or their spouse or dependent child.

Critical illness or injury of an individual or spouse or dependent child.

Loss of primary residence as a result of a fire, storm, or similar disaster.

Critical illness or injury resulting in a disability of the individual.

Accident with recoverable injuries of the individual.

Damage to individuals primary residence as a result of a fire, storm, or similar.

Please Provide Information on The Life Changing Incident

Date of Submission

Signature of Submitter

Thanks for submitting!