Fillable DDPSO Flyer And Fillable Application (Oregon State Data Center)

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DDPSO Flyer And Fillable Application (Oregon State Data Center)

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APPLICATION & CERTIFICATION OF ELIGIBILITY FOR THE DECEASED OR
DISABLED PUBLIC SAFETY OFFICER GRANT
*If Deceased or Disabled Public Safety Officer’s supervisor is no longer employed by the original agency/department,
certifying signature may be provided by a personnel officer or other appropriate official currently employed by the
agency/department.
Academic Year: ________________ (example: 2018-19)
Applicant’s Name: Last First MI
Social Security Number
Date of Birth mm-dd-yyyy
Telephone Number
Permanent Address:
Street, PO Box, and/or Apartment Number
City
State
Name of Disabled or Deceased Oregon Public Safety Officer
Relationship to Applicant
College or University You Plan to Attend
Year in College (example 1, 2, 3, 4)
# of Credits per Term
Expected Graduation Date
By signing this application, I certify that the accuracy of this completed form, and, if requested,
agree to provide proof of this information.
Signature of Applicant
Date
SIGNATURE OF THE PUBLIC SAFETY OFFICER’S SUPERVISOR*
I certify that the Oregon public safety officer named above was permanently disabled or killed in the line of
duty, and that the officer was employed in one of the following fields: a paid career firefighter, State Fire
Marshal, chief deputy fire marshal, deputy state fire marshal, police chief, police officer, sheriff, deputy
sheriff, county adult parole officer, probation officer, correction officer, or investigator of the criminal Justice
division of the Department of Justice.
Signature of Supervisor*
Title
Date
Address
Telephone number
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APPLICATION & CERTIFICATION OF ELIGIBILITY FOR THE DECEASED OR
DISABLED PUBLIC SAFETY OFFICER GRANT
Who is eligible?
Applicants for awards must be dependents of a public safety officer in the state of Oregon, as defined by
ORS 181A.355, who was killed or disabled in the line of duty as defined by ORS 243.954. Eligible
dependents include the natural child, adopted child or stepchild of eligible public safety officers.
Eligible public safety officers include:
•Corrections officers
•Fire service professionals
•Parole and probation officers
•Police officers
•Reserve officers
•Youth correction officers
Applicants must meet all of the following criteria:
•Be dependents of a public safety officer in the state of Oregon who suffered death or permanent total
disability suffered by a public safety officer while on or off duty as defined by ORS 243.954;
•Be under 25 years of age at the time of submitting the application;
•Not have achieved a baccalaureate or higher degree from any post-secondary institution;
•Be Oregon residents for at least 12 months prior to applying as defined in OAR 575-030-0005(1);
•Be a citizen of the United States, or be in the United States for other than a temporary purpose and
intend to become a permanent resident; and
•Be enrolled or planning to enroll as full-time students at an Oregon Opportunity Grant eligible Oregon-
based postsecondary institution.
A student who is awarded a scholarship, in addition to satisfying all other eligibility criteria, must maintain
satisfactory academic progress (SAP) as defined by the institution of higher education.
How do I apply?
Complete the Application and Certification of Eligibility for the Deceased or Disabled Public Safety Officer
Grant.
Mail completed Application and Certification to:
Office of Student Access and Completion (OSAC)
Attn: DDPSO Grant Administrator
1500 Valley River Drive, Suite 100
Eugene, OR 97401
You also must complete the Free Application for Federal Student Aid (FAFSA) need analysis form for all
academic years for which you are receiving the grant as soon after October 1 as possible.
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DDPSO Flyer And Fillable Application (Oregon State Data Center)

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Completed 26 July 2020

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