Middle Park Medical Foundation EAF Application

Middle Park Medical Foundation Employee Assistance Fund Application
Scope:

This fund applies to any Middle Park Health employee who falls on financial hard times due to unforeseen and uncontrollable circumstances that require immediate action and an urgent need for assistance and relief. Examples include death in immediate family, accidents, illness, natural disaster, victim of a crime, etc.
Purpose

The purpose is to provide financial assistance for unexpected financial hardships due to emergency situations that have occurred within the last 60 days of this application. Middle Park Medical Foundation's EAF is designed to be used for this specific event and not as an associate loan program to pay for routine or foreseeable financial issues.
Distribution of Support:
Any Middle Park Health (MPH) employee who has seen unexpected financial hardships due to emergency situations that have occurred within the last 60 days may apply for Middle Park Medical Foundation's (MPMF) EAF funds for financial relief due to an unforeseen and unavoidable circumstance (triggering event).

Grant award amounts depend on employment status as defined by MPH policy:

Full-time employees can receive up to $2,400.00.

Part-time employees can receive up to $1,800.00.

PRN employees can receive up to $1,200.00.

Once the maximum amount is reached, the employee can no longer apply for relief from that same triggering event. If a new and unrelated triggering event occurs, the employee is encouraged to apply for a new grant for relief from the new triggering event. Documentation of event, expenses, and financial hardship required. The applying employee must be a current employee with six months or more of service and in good standing with no performance issues within the past 12 months at Middle Park Health. Grants will be determined through an objective evaluation.

Applications will be reviewed by the MPMF E.A.F. committee. After an objective review, funds will be awarded based on the needs of the individual. If approved, checks will be made payable to the creditors, not the associate. Exceptions should be considered only under extenuating circumstances, such as an estimated need for future food/necessities. For payments made directly to a creditor, remittance information such as bills and/or invoices to be paid must accompany the request for payment. Individuals can be reimbursed for expenses due to displacement with provided receipts/proof. Checks may be picked up by the associate upon showing their Middle Park Health I.D. badge. Applications will be reviewed, and a decision will be made by the MPMF E.A.F. Committee.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
My employment with MPH status is:
Please describe the triggering event (event that caused you financial hardship).
Date of event

MonthDayYear
Date
Was the triggering event (check each box that applies):
Please describe how the event was unforseen, uncontrollable, and not preventable.
Please list the expenses and amounts associated with the triggering event (example - ER Visit: $1,000).
Please describe the details of each expense .
Total Amount Requested (up to $2,400):
Please provide documents backing your request for funds related to the triggering event that are listed above. - i.e. bills, statements, invoices, receipts, etc.

Cancelof
What are the steps you have taken to begin your path to recovery from this event?
What additional information do you believe is valuable important for the committee to be aware of?
Eligibility is dependent the applicant having at least six consecutive months of service with Middle Park Health and in good standing with no performance issues within the past 12 months at Middle Park Health.

I do hereby attest that the information stated in this application is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability and is grounds for immediate dismissal of this application and any further application of grants through Middle Park Medical Foundation.
Signature
Should be Empty:

Middle Park Medical Foundation Employee Assistance Fund Application

Scope:

Purpose

Distribution of Support: