Emergency Financial Assistance Grant Application (FHCRC)

Please print out this form and fill out and send completed form to Human Resources, Mail Stop J1-105.

Please refer to the Employee Emergency Fund Program for further information.

Date:	Name:
Address:
Please check one Active Employee Former Employee (separated from employment 6 months or less) Retiree (retired 6 months or less) Surviving Dependents or Family Members of an eligible employee
Social Security Number: (for id purposes)	Employee Number:
Home Phone:	Work Phone:
Current Job/Position:	Gross Salary:
Please check one Hourly Monthly	Please check one Part-Time Full-Time
Amount Requested: $
Please answer the following questions completely. All information given will be confidential. Financial disclosure is required. (If additional space is needed, use a blank sheet and attach to the application)
1. What is the purpose of this grant? Describe the circumstances that led to the emergency.
2. How will the grant be spent? Please be specific.
3. When do you need the grant?
4. Have you used up significant portions of existing assets to meet this emergency? Please describe.
5. Have you ever applied for a grant from this fund before? If so, when and what was the result?
6. If the grant is not awarded, what are the alternatives to meet the emergency? Please describe.
7. Other comments/information that would be helpful in reviewing this grant application?.
Please attach copies of the following: Paycheck stubs for the last two months Bank statements (savings, checking, etc.) Pension statements (IRA, mutual funds, stocks, bonds, etc. Please attach copies of the following (check whichever is applicable): Specific bills you are requesting funds for Death certificate (deceased employee/dependent) Police/fire reports Other__________________________________________________________ __________________________________________________________________ __________________________________________________________________
I certify that the information provided in this grant application is true and correct to the best of my knowledge. Any intentional misrepresentation of information contained in this application will result in forfeiting this and any future grant application. I authorize the Committee administering this program to verify my employment earnings records, bank accounts, and any other assets needed to process my grant application. Furthermore, I understand that any grant I receive from this program will be treated as taxable income subject to FICA and Federal Withholding.
Signature:	Date:
For Committee Use Only Grant Approval: Yes No
Reason:
Amount Approved: $
Make Check Payable To:

Revised February 7, 1997.

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