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Advance Financial Cares Fund Form

Please fill out ALL parts of the form below. Incomplete form submissions may not receive a response.

General Information

Applicant Name:

Street Address:

City:

State:

Zip:

County:

You will be notified of approval by email or phone, so please provide a valid email address and phone number:

Daytime Phone:

Other Phone:

Email Address:

Current Mailing Address (if different from above):

City:

State:

Zip:

Department:

Job Title:

Date of Hire:

Supervisor's Name:

Employee Name:

Describe Your Situation

Which qualifying situation cased the financial hardship?

  • Natural Disaster
  • Life-Threatening Illness or Injury
  • Death Incident
  • Catastrophic or Extreme Circumstance

Name of Incident: (Example: Tornado, Fire, Flood, Type of Injury, Name of Illness, Domestic Abuse)

Date of Incident: (Must be within past 60 days)

Who has been affected by the situation?

Is the affected person covered by medical or disability insurance?

Have they applied for disability benefits?

If your home was damaged, will insurance cover part of the cost?

Your deductible amount?

How many people live in your household?

Number of adults:

Number of children:

Describe what has happened to cause your financial hardship:

Describe in detail your immediate basic needs:

How will this grant help you recover from the immediate financial crisis?

Please tell us anything else that would help in understanding the circumstances of the hardship you or your family is experiencing. If this application is being completed by someone other than the employee (as in the case of death), please explain and provide a contact name and information.

Have any other resources been considered or used, such as American Red Cross, Salvation Army, or other similar social service agencies? Please comment on efforts and response.

Vendor Information

To pay the vendor on your behalf, we need to know the name, address, phone number and account number of the vendor who needs to be paid:

Vendor 1:

Name:

Address:

Phone Number:

Account Number:

Vendor 2:

Name:

Address:

Phone Number:

Account Number:

Vendor 3

Name:

Address:

Phone Number:

Account Number: