Instructions: Complete this form and send it to the State Fire Marshal for certification. The State Fire Marshal
will send the certified form to the financial aid office at the educational institution checked below.
Address: State Fire Marshal, Herschler Building, 1st Floor West, Cheyenne, Wyoming 82002
Name of Applicant:
Social Security No.:
Mailing Address:
Date of Birth:
Telephone No.:
E-mail Address:
To which school do you wish to have the tuition benefit applied:
Casper College ___ Northwest College
Central Wyoming College ___ Sheridan College
Eastern Wyoming College ___ University of Wyoming
Laramie County Community College ___ Western Wyoming Community College
School year for which you are applying:
Fall Semester
Spring Semester
Summer Semester
I HEREBY CERTIFY that all statements made herein are true and complete to the best of my knowledge
and belief and I herewith apply for a program of education under W.S. 35-9-161.
Signature of Applicant:
Date Signed:
Name of Deceased Firefighter:
Social Security No. of Firefighter:
Name of Fire Department/District:
Date of Death of Firefighter:
Applicant's Relationship to Deceased:
This is to certify that the decedent listed above was a firefighter in the service of a paid or volunteer fire
department or district in Wyoming, the decedent died while acting within the scope of his/her duties
and the applicant is the decedent's dependent and qualified for free tuition under W.S. 35-9-161.
Printed Name and Signature of State Fire Marshal:
Date Signed:
Original sent by Fire Marshal to educational institution (financial aid office)
Copy sent by Fire Marshal to applicant
State Fire Marshal Certification
WYOMING SURVIVORS OF DECEASED FIREFIGHTERS
TUITION BENEFIT APPLICATION
STATE FIRE MARSHAL CERTIFICATION
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