Heart & Soul Employee Emergency Fund Application No information will be shared with a third party if an award is provided. Employee Information Representative of the Employee (if applicable) If this application is being completed by a representative of the employee Details of Emergency Which qualifying incident caused your current financial hardship (See guidelines for qualifying financial hardships below) Qualifying incident * Following a Disaster Unexpected Medical/Dental Expenses (not covered by health insurance) Death of immediate family Miscellaneous If Miscellaneous, please explain. Was the incident covered by Insurance? * No Yes If yes, is your application today being submitted after insurance coverage has applied? No Yes If no, why not? 1. Describe the circumstances surrounding the need for assistance. Please include with this application any documents substantiating or supporting your need for assistance. * Please email any documents substantiating or supporting your need for assistance to [email protected] after submitting your request. 2. What is the amount needed to work through this emergency? Note: Because of the limited sources of income for this fund, a grant ranging from €50.00 to €400.00 gross may be allowed for each emergency situation. The actual amount of the financial assistance grant is determined by the Emergency Assistance Committee (EAC) and is based on an analysis of need, as described in the " DETERMINATION OF NEED" section of this document and the funding available at the time of the request. 3. Please share other comments or information that would be helpful in determining your request. By checking this box, I certify that the information provided is true and correct to the best of my knowledge, and that any money received will be used to relieve the stated financial hardship. I agree to provide the EAC administering this program with documentation regarding the hardship upon request. Any intentional misrepresentation of information contained in this application or shared during its review will result in forfeiting this and any future application for assistance and a potential demand for repayment of funds issued. Furthermore, I understand that the completion of this application does not guarantee funding, and that if needed I will address any concerns or questions related to my application. IF COMPLETED BY REPRESENTATIVE OF THE EMPLOYEE: By checking this box, I declare that I am authorized to complete this application and attest to the statement above on behalf of the employee.
