The Equity Employee Hardship Program Application

The Equity Employee Hardship Program Application
CONTACT: The Equity Employee Hardship Program Relationship Manager - hardship@southeasternillinois.org - 217.253.8939 (call or text)

PURPOSE: Provide short-term assistance to employees that are facing an unexpected financial hardship because of a qualified disaster, life-threatening illness or injury, death or other catastrophic or extreme circumstances beyond the employee's control.

ELIGIBILITY: All Effingham Equity employees who are employed full-time for at least ninety (90) days and seasonal employeeds who have worked 1,000 hours prior to submitting this application, are eligible to apply for grants. In the case of death of the employee, then spouse, domestic partner or eligible dependents may apply. An employee can only be approved for assistance once within a twelve-month period.

GRANTS: The maximum grant amount available for assistance is $2,500; 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.
Section A: Will You Qualify?
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 60 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.

Life-Threatening or Serious Illness Or Injury: For the employee, spouse or domestic partner, and eligible dependents. 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, or eligible 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.
Section B: Information About You
Employee Name *
Date of Hire* *

Month Day Year
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? *

Yes No
If YES, date applied

Month Day Year
Date
Marital Status

Single Married Widowed Divorced/Separated
Family Members (Spouse/Dependents Only) - List each member living with you, their relationship to you, and their age.
Section C: Personal Financial Statement
File Upload - Please attach copies of most recent pay stubs for each wage earner. *

Cancel of
Assets
Cash *
Savings Account Balance *
Other accessible cash or investments *
Real Estate *
Vehicles (car, boats, RVs) *
Total Assets
Your Monthly Living Expenses
Rent or Mortgage *
Utilities *
Food *
Medical Expenses *
Car Loans *
Gas/Incidentals *
Other
Total Monthly Living Expenses
Your Monthly Household Income
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
Section D: Describe Your Situation
Which qualifying situation caused the financial hardship? (Read the descriptions in Section A. Call or text your Equity Employee 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 reports Life-Threatening or Serious Illness or Injury -attach doctor or medical documentation Death - attach death certificate Catastrophic or Extreme Circumstances - attach police, fire or other official indicent report
File Upload

Cancel of
Date of Incident *

Month Day Year
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? *
Section E: APPROVAL
The Equity Employee Hardship Program Relationship Manager will review your application and determine if you are approved, denied or if more 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.
Section F: DECLARATIONS AND AGREEMENT
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 The Equity 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 The Equity. The fiduciary expectations of all Effingham Equity employees are paramount and a breach of these standards will be reported to The Equity.

Your signature below certifies that the information provided is true and complete, authorizes The Equity Employee Hardship Fund, administered by Southeastern Illinois Community Foundation, to obtain and/or verify all information necessary to process this application,and releases The Equity 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 *

Month Day Year
Date
The Equity Employee Hardship Fund administered by Southeastern Illinois Community Foundation, PO Box 1211, Effingham, IL 62401 Phone/Text: 217-253-8939

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The Equity Employee 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