Application Form ApplicantName(Required) First Middle Last Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) MM slash DD slash YYYY Sex(Required)SexMaleFemaleOtherJurisdiction/Agency(Required)Jurisdiction/AgencyAlexandria PoliceAlexandria SheriffArlington PoliceArlington SheriffFairfax City PoliceFairfax County PoliceFairfax County SheriffFairfax DPSCFalls Church PoliceFalls Church SheriffFauquier County SheriffFredericksburg PoliceFredericksburg SheriffHerndon PoliceLoudoun County SheriffManassas City PoliceManassas Park PolicePrince William PolicePrince William SheriffStafford County SheriffVienna PoliceWarrenton PoliceEmployee ID #(Required)This field is hidden when viewing the formAgeSorry...you must be 18+ to submit this formEmail(Required) EnrollmentEnrollment Type(Required)Select OneOpen Season (October)New Hire/Swear in (30 days)Date of Hire/Swear-In(Required) MM slash DD slash YYYY This October open enrollment period has ended. Please apply again during the next October open enrollment period or reach out to your agency’s Director.This October open enrollment period has ended. Please apply again during the next October open enrollment period or reach out to your agency’s Director.Payroll Deduction I elect to enroll in Law Enforcement Benevolent Fund of NoVA. I authorize a $2.50 allotment per pay period through payroll deduction. A payroll deduction card must be submitted with this form if your agency requires. Other Dues I elect to enroll in the Law Enforcement Benevolent Fund of NoVA. I authorize the Herndon FOP to contribute $2.50 per pay period on my behalf. The purpose of the Law Enforcement Benevolent Fund of NoVA is to provide funds to the designated beneficiary (ies) of a deceased member immediately upon the death of a member from any cause. Upon notification of the death of any member, the Fund will pay no less than the sum of $25,000 to the member's designated beneficiary (ies) as listed below. You are eligible for this coverage within 30 days of being hired or sworn in as a new agency employee. After this period you will need to provide evidence of good health in order to be eligible for this program, unless you enroll during an open enrollment period. When a minor child (ren) under the age of 18 is listed as a beneficiary, payment may be delayed until the legal financial guardian is identified by the court. Estates and trusts may not be designated as the primary beneficiary (ies). All administrative and operational matters pertaining to the Fund are pursuant to the bylaws of the Law Enforcement Benevolent Fund of NoVA. Membership in the Fund terminates upon separation from the participating agency. Please use a Change of Status form to update any information.Primary Beneficiary(ies)I hereby designate the following person(s) as my beneficiary(ies) for the LEBF Primary Beneficiary(ies): in equal shares or as indicated below:Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 1 AgeThis field is hidden when viewing the formBeneficiary 1 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Beneficiary Add 2nd Beneficiary Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 2 AgeThis field is hidden when viewing the formBeneficiary 2 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contingent Beneficiary(ies) checkbox Add Contingent Beneficiary(ies) Contingent Beneficiary(ies)As shall be living, and if no such Primary Beneficiary is then living, Contingent Beneficiary(ies): In equal shares or as designated below: Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 3 AgeThis field is hidden when viewing the formBeneficiary 3 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 2nd Beneficiary Add 2nd Beneficiary Name(Required) First Middle Last Phone Number(Required)Date of Birth(Required) MM slash DD slash YYYY Relationship(Required)RelationshipSpouseParentChildSiblingGrandchildCousinFriendOtherPercent(Required)Percent100999897969594939291908988878685848382818079787776757473727170696867666564636261605958575655545352515049484746454443424140393837363534333231302928272625242322212019181716151413121110987654321This field is hidden when viewing the formBeneficiary 4 AgeThis field is hidden when viewing the formBeneficiary 4 ValueNote: Beneficiaries cannot be a juvenile. Find out why here. Address(Required) Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature(Required)This field is hidden when viewing the formCurrent Date MM slash DD slash YYYY Today's Date: 12/21/2024Sorry...you must be 18+ to submit this formThis field is hidden when viewing the formdeductionsThis field is hidden when viewing the formContingent Beneficiary Percent VALThis field is hidden when viewing the formPrimary Beneficiary PercentThis field is hidden when viewing the formContingent Beneficiary PercentThis field is hidden when viewing the formJuvenile Notification ValueNote: Beneficiaries cannot be a juvenile.Please check a deduction Box to proceedPrimary Beneficiary Percent must total to 100...Please adjustContingent Beneficiary Percent must total to 100...Please adjustCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. 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