Addus ACTS Program Application

The Addus ACTS employee assistance fund is a tax-deductible program designed to assist employees through financial hardship resulting from catastrophic events beyond their control, when all other means of financial assistance has been exhausted. The Addus ACTS request selection committee is represented by members from all business lines, and some of the support departments, typically below the director level. This is truly a “For Employees by Employees Endeavor.”

Qualifying requests may include assistance for, but are not limited to the following:

Disaster assistance (fires, floods, hurricanes, tornados)
Basic living expenses due to a catastrophic event (food, utilities, etc.)
Emergency situations involving deaths and medical catastrophes
Housing assistance to prevent a mortgage foreclosure or eviction due to a catastrophic event
Costs associated with being a victim of a crime

SECTION 1: EMPLOYEE CONTACT INFORMATION

Employee First and Last Name:*

What Business Line do you work in?*

Your Current Position:*

Work Location/Branch Name:*

Best Phone Number to Reach You:*

Preferred Email Address*

example@example.com

Hire Date:*

Martial Status:*

Employment Status:*

Please Select the Type of Assistance Needed:*

HousingUtilitiesFoodOther

If you selected other, please provide details:*

SECTION 2: FOR DISASTER RELIEF ONLY (If unknown, please skip)

Do you have homeowners or renter's insurance?*

YesNo

Have you applied for or received any other type of insurance?*

YesNo

If you selected yes, what is the amount or type of assistance you have received or applied for:

SECTION 3: FINANCIAL RESOURCES

Do you have any of these other resources available to you?*

Savings401(k) loanI have no other resources available

If you selected that you have other resources available above, please give details on how this is contributing to your need:*

Employee's Bi-Weekly Salary:*

Spouce's Bi-Weekly Salary: (If applicable)*

SECTION 4: DOCUMENTATION OF NEEDS

Please provide details pertaining to your event along with supporting documentation*

Please provide details of your current needs and the amount being requested along with supporting documentation (utility bill, mortgage, medical bills, etc.)*

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