Form OJP form 1240 OJP form 1240 PSOBEA

OMB No. 1121-0220 (Expires: 01/31/2007)

U.S. Department of Justice
Office of Justice Programs
Bureau of Justice Assistance
Public Safety Officers’ Benefits Program
Washington, DC 20531

APPLICATION FOR
PUBLIC SAFETY OFFICERS’
EDUCATIONAL ASSISTANCE
(42 U.S.C. 3796d)

FAX (202) 616-0314

Important: No benefits can be paid unless a completed application has been received (28 CFR Part 32.20). The information requested on
this form is necessary to determine your eligibility for educational assistance. Your responses are considered confidential (38 USC 5701) and may
be disclosed outside of the Office of Justice Programs only if the disclosure is authorized under the Privacy Act. Paperwork Reduction Notice:
Under the Paperwork Reduction Act, a person is not required to respond to a collection of information unless it displays a currently valid OMB
control number. We try to create forms and instructions that are accurate, can be easily understood, and that impose the least possible burden on
you to provide us with information. The estimated average time to complete and file this application is approximately 20 minutes. If you have
comments regarding the accuracy of this estimate or suggestions for making this form more simple, please write to the Public Safety Officers’
Benefits Program at the above address.
PART I – APPLICANT INFORMATION
1. Name (First, Middle, Last)

2. Social Security Number

9 Spouse

4. Relationship of Applicant to Public Safety Officer
5. Applicant’s PERMANENT Mailing Address
(Include Street/P.O. Box, City, State, Zip Code)

3. Date of Birth

9 Child

6. Contact Information
The contact for all educational assistance matters will be the:
applicant’s parent / guardian 9
applicant 9
__________________________________
name of parent / guardian
(For phone numbers, include area code)
Home Phone: ________________________
Day Phone:

________________________

Cell Phone:

________________________

E-Mail Address: _________________________________
7. Payment Information

9 I would like to receive my educational benefits by check.
9 I would like to receive my educational benefits by Direct Deposit.
Complete the following for Direct Deposits only:
Name of Bank: ______________________________________
Type of Account:

9 Savings 9 Checking

Account Number: ____________________________________
Bank’s 9-Digit Routing Number: __ __ __ __ __ __ __ __ __
PLEASE CONTACT THE PSOB OFFICE IF ANY OF THE INFORMATION
IN PART I CHANGES AFTER YOU SUBMIT YOUR APPLICATION
OJP FORM 1240/20 (REV 4/04)

PART II – PUBLIC SAFETY OFFICER INFORMATION
8. Name of Public Safety Officer (First, Middle, Last)

9. Date of death or disability

10. Officer’s Public Safety Agency (Agency Name, City, State)

PART III – APPLICANT’S RECORD OF EDUCATION
11.
Type of School

Graduation or
Expected
Graduation Date

Dates Attended
From

To

Degree / Certification
Attempting or Achieved

Name and
Location of School

High School
College / Trade

hr

College / Trade
College / Trade
College / Trade

PART IV – SIGNATURES
I certify that all information set forth above is true to the best of my knowledge and belief. I authorize the release of school records to the
Department of Justice for the sole purpose of administering the PSOEA Program. I understand that I must provide the PSOB office with
a copy of my transcript each time I apply for benefits, and that failure to maintain satisfactory progress may result in a loss of additional
assistance.
I certify that the PSOEA benefits being provided to me will only be used for educational or vocational purposes consistent with
42 USC 3796d and 28 CFR 32. I further certify that I am not in default on any student loans provided or guaranteed by the United States
Government.

12. Signature of Applicant

13. Date Signed

14. If the applicant is under the age of 18, the following items must be completed:
I am the applicant’s

9 Parent 9 Guardian

_____________________________________________
Printed Name
Parent / Guardian’s Address

_________________________________________
Signature
Parent / Guardian’s Phone Number

PENALTY – A false statement or information associated with this application may be grounds for nonpayment
of benefits and may be punishable by fine or imprisonment (18 USC 1001). All information given will be
considered in reviewing your application for benefits and is subject to investigation.