Hardship Fund Request

Employee Name *

First Name

Last Name

Employee Phone Number *

(###)

###

####

I am facing a major financial hardship that prevents my basic needs from being met. *

Yes

No

Employment Status *

I have been out of work for at least 2 weeks within the past 4 months.

I have had my work hours reduced for at least 30 days, but will be returning to regular hours within 6 months.

I am regularly employed, but have experienced short-term (less than 6 months) unemployment within the past 90 days.

I am regularly employed and have not experienced unemployment or reduced work hours within the past 6 months.

Type of Hardship (check all that apply) *

I have faced/am facing a medical issue keeping me off work (unpaid) for 2 or more weeks.

I have had a death in my immediate family resulting in 2 or more weeks beyond standard bereavement leave. (Note: funeral costs and travel are not covered by this fund.)

I have dealt with/am dealing with unpaid child support of at least 1 month.

I am facing food insecurity.

I am facing loss of housing or am seeking housing.

I am a victim of domestic violence.

I am experiencing a significant event that could not have been expected. (Please describe under Additional Information below.)