Heartland Dental Foundation Economic Hardship Program Application

CONTACT: Heartland Dental Foundation Economic Hardship Program Relationship Manager - hardship@southeasternillinois.org - 217.253.8939 (call or text)

PURPOSE: Help Heartland Dental supported doctors, team members and support professionals who are experiencing economic hardship and are unable to afford housing, utilities, and other basic living needs because of a qualified disaster, serious or life-threatening illness or injury, death or other catastrophic or extreme circumstances beyond the employee's control.

ELIGIBILITY: All Heartland Dental employees, supported doctors and support professionals who are employed part-time or full-time for at least six (6) months prior to submitting this application AND have experienced a qualifying incident (see Section A for definitions) within 90 days of the date of application. In the event the employee cannot complete the application themselves, the spouse or eligible dependents may apply on their behalf. An employee can only be approved for assistance once within a twelve-month period.

GRANTS: The maximum grant amount available for assistance is $5,000 for any death incident and $2,500 for all other incidents; however, grant amounts vary based upon the nature of the qualifying incident and related expenses. Awards from the fund are intended to assist the recipient associate through the crisis; they are not intended to make the associate whole. All payments are made directly to vendors as bill payments; assistance funds are not sent directly to applicants.

To qualify for this program and receive assistance you must meet certain requirements:

1) You must meet employment eligibility requirements as outlined above.

2)You must be experiencing financial hardship that affects your ability to pay for basic living needs.

3) The qualifying incident (see categories below) must have happened within the past 90 days.

Natural Disaster: This includes but is not limited to: a wildfire, flood, tornado, hurricane, severe storms or earthquake, that have damaged or destroyed the employee's primary residence or have required the employee to evacuate their primary residence. The Fund cannot pay to repair other property and cannot pay to replace non-essential items, such as electronics or furnishings. Photographs or insurance reports may be required.

Serious Or Life-Threatening Illness or Injury: For the employee, spouse or domestic partner, children up to 26 and other eligible IRS dependent(s) who have medical incidents that result in a certified inability to report to work for a minimum of 5 consecutive working days. In the case of COVID diagnosis, a hospitalization is required. The Fund is not a substitute for medical insurance and is not intended to cover insurance deductibles. Employees do not automatically qualify for a grant when they, or their dependents, are diagnosed with or suffer a life-threatening or serious illness or injury. There must be resulting financial need including an inability to pay basic living expenses. IRS tax documentation may be required to verify dependent status. Doctor confirmation or medical documentation will be required.

Death: This includes the death of the employee, spouse, domestic partner, children up to 26 and other eligible IRS dependent(s). The loss of income, cost of burial or funeral expenses, or resulting medical bills prevents an employee or the employee's family from affording basic living expenses. Copy of the death certificate or obituary will be required.

Catastrophic or Extreme Circumstances: This includes but is not limited to: fire, major home damage that could not be prevented, serious crime against the employee (robbery, arson, assault, domestic abuse, extreme vandalism), or another reportable incident beyond the employee's control that impacts the ability to afford basic needs. Catastrophic or extreme circumstances do not include: credit card debt, home foreclosure, wage garnishment, bankruptcy, child support payment, car repair, taxes, or accumulated financial distress. Police, Fire or other official incident report may be required.

Employee Name*

Date of Hire**

Date

Permanent Address*

City*

State*

Zip*

County/Parish

Daytime Phone*

Other Phone

Email Address*

example@example.com

If you can not receive mail at your permanent home address due to the qualifying incident, please provide another mailing address:

Temporary Address

City

State

Zip

**Approval Notification will be sent to you by mail and email, so please provide a valid mailing and email address.

Have you applied for this program before?*

YesNo

If YES, date applied

Date

Marital Status

SingleMarriedWidowedDivorced/Separated

Family Members (Spouse/Dependents Only) - List each member living with you, their relationship to you, and their age.

File Upload - Please attach copies of most recent pay stubs for each wage earner.*

Cash (in hand & checking)*

Savings Account Balance*

Real Estate*

Other accessible cash or investments*

Vehicles (car, boats, RVs)*

Total Assets

Rent or Mortgage*

Utilities*

Food*

Medical Expenses*

Car Loans*

Gas/Incidentals*

Other

Total Monthly Living Expenses

Your average monthly net income (after deductions)*

Spouse/Partner's average monthly net income (after deductions)*

Child Support Income per month (self and/or spouse/partner)*

Social Security/Pension Income (self and/or spouse/partner)*

Unemployment Income per month (spouse/partner)*

Other Income received monthly

Total Monthly Household Income

Which qualifying situation caused the financial hardship? (Read the descriptions in Section A. Call or text your Heartland Dental Foundation Economic Hardship Program Manager at 217-253-8939 with questions.)

Choose the category that best fits your situation and attach corresponding documents below.*

Natural Disaster - attach photographs or insurance reportsSerious or Life-Threatening Illness or Injury -attach doctor or medical documentationDeath - attach death certificateCatastrophic or Extreme Circumstances - attach police, fire or other official indicent report

File Upload*

Date of Incident*

Date

Type of Incident*

Is the affected person covered by medical or disability insurance?

Have they applied for disability?

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

Your deductible amount?

Describe the incident in detail. What happened? How has this created a financial hardship?*

The Heartland Dental Foundation Economic Hardship Program Relationship Manager will review your application and reach out if additional information is needed to make a decision. If approved for assistance, a Vendor Payment Request Form will be sent to you via email (as provided on this application). The Vendor Payment Request Form will include instructions on submitting copies of bills and supporting documentation for payments.

No employee is entitled to receive a grant, either by their employment, their history of contributions to the Fund or because of any precedent inferred from a previous grant from the Fund. Grants will not be made before an employee has demonstrated an immediate financial need and provided all required documentation.

This application will be treated in a confidential manner by Southeastern Illinois Community Foundation; however non-identifying statistical information will be reported to Heartland Dental on a periodic basis.

Employees are expected to provide truthful and accurate information. In its due diligence, if the Foundation discovers any information to be untrue, it shall have the right to unilaterally waive its confidentiality and report its findings to Heartland Dental. The fiduciary expectations of all Heartland Dental employees are paramount and a breach of these standards will be reported to Heartland Dental.

Your signature below certifies that the information provided is true and complete, authorizes Heartland Dental Foundation Economic Hardship Fund, administered by Southeastern Illinois Community Foundation, to obtain and/or verify all information necessary to process this application,and releases Heartland Dental and Southeastern Illinois Community Foundation from any liability associated with the rejection of or funding of this application. In addition, you agree to provide the requested documentation supporting the information provided.

Applicant's Signature*

Clear

Date*

Date

The Heartland Dental Foundation administered by Southeastern Illinois Community Foundation, PO Box 1211, Effingham, IL 62401 Phone/Text: 217-253-8939

Click "Save" below if you need to finish at a later time.

Click "Submit" below if your application is complete and ready to be submitted.

HEARTLAND DENTAL FOUNDATION ECONOMIC HARDSHIP PROGRAM APPLICATION

Section A: Will You Qualify?

Section B: Information About You

Section C: Personal Financial Statement

Assets

Your Monthly Living Expenses

Your Monthly Household Income

Section D: Describe Your Situation

Section E: APPROVAL

Section F: DECLARATIONS AND AGREEMENT