Gentex Employee Hardship Fund Grant Application Part 1

Gentex Employee Hardship Fund Grant Application Part 1

Eligibility based on Employment Status, Previous Applications and Events, and Qualifying Event
THE PROGRAM

The Gentex Employee Hardship Fund was established by Gentex Corp. to help Gentex employees cope with unexpected hardships through grants administered by the Community Foundation of the Holland/Zeeland Area (CFHZ).

ELIGIBILITY

Directors and Executive Officers of Gentex and their Qualifying Household Members are not eligible to receive grants from the Fund. The Fund is not a substitute for insurance coverage.
- The following individuals may apply: Full Time employees, Part Time employees, employees on Approved Medical Leave, employees on Approved Leave of Absence, and, in the case of the employee's death, the Qualifying Household Member of an employee may apply.
- The employee must be employed with Gentex on the date of application and for at least one year prior to the date of application and employment must be in the United States.
- Grants can be made to help pay for limited types of essential living expenses (as specified on the application) after a Qualifying Event(s) that occurred during the employee's employment with Gentex.
- Qualifying Events include: Natural Disaster, including government declared disasters, such as: flood, wildfire, tornado, earthquake, tsunami, volcanic eruption, blizzard, drought, cyclone, hurricane, typhoon, or severe storms; Other Events Impacting the Primary Residence, such as fire, flood, or unusual life-altering situations that resulted in damage to the primary residence and was not covered by insurance; Terrorist Action; Common Carrier Disaster, a disaster resulting from an accident involving a common carrier such as a bus, train, ferry, plane, or truck; Epidemic; Military Deployment when the employee or their Qualifying Household Member is called to active duty; Serious Illness or Injury or Non-routine/Exceptional Medical Expenses of employee or their Qualifying Household Member; Violent Crime against employee or their Qualifying Household Member; Domestic Abuse; and Death of employee or their Qualifying Household Member.
- The applicant must be able to demonstrate their unexpected financial hardship and immediate financial need as a result of the Qualifying Event. Documentation of income, assets, expenses, insurance, and any other available sources of aid is required so an objective determination can be made. Additional documentation requirements will vary depending on the Qualifying Event.
GRANT RULES AND PROCEDURES
- An application must be submitted to CFHZ within 180 days of a Qualifying Event. Covid 19 is not a Qualifying Event except in the case of serious illness which began within 180 days of application.
- The CFHZ Program Officer will contact the applicant within two business days after receiving the application.
- Grants will only be made payable in the form of check(s) to service provider(s). The applicant will be notified of the payment(s). Funds will not be sent directly to the applicant. Grants cannot be made payable to the employee.
- The minimum grant amount per Qualifying Event is $500. The maximum grant amount per Qualifying Event is $5,000, not to exceed actual out-of-pocket expenses not covered by insurance or another grant. The maximum lifetime grant amount per employee is $10,000, and employees may not receive assistance for more than three Qualifying Events in a lifetime.
- No applicant 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.
- The Fund is not a substitute for insurance coverage.
- Grants are at the sole discretion of the CFHZ. The fund may be terminated at any time without notice.
- Grants cannot be made to pay for other expenses, such as legal fees; insurance premiums or deductibles; non-essential utilities (cable, internet, phone, etc.); car payments or repairs, unless necessitated by a Qualifying Event; accumulated financial issues or credit card debt; or accidental damage due to negligence.
- An applicant must complete all three parts of the grant application within 90 days of the date that part 1 was submitted. If the applicant does not complete the grant application process within this time frame without cause, their application will be denied.
- An applicant who already has benefitted from a grant from the Fund may reapply after a 365-day waiting period. The 365-day waiting period applies even if another Qualifying Event occurs during the same year. An applicant who has had their application denied may reapply for a different Qualifying Event after a 90-day waiting period.
- Applications and supporting documentation will be treated in a confidential manner by CFHZ; however non-identifying statistical information will be reported to Gentex on a periodic basis.
- Additional rules and procedures are specified on the application and may change from time to time.

Contact Information

Employee
Gentex Employee Name*

First NameLast Name
Employee/Badge Number*
(The number on your employee ID badge)
Daytime Phone Number*
Please enter a valid phone number.
Other Phone Number
Please enter a valid phone number.
Email*
example@example.com
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Have you worked at Gentex for at least one year prior to the date of this application?*

YesNo

INELIGIBLE HIRE DATE

Unfortunately, because you answered "no" to the question "Have you worked at Gentex for at least one year prior to the date of this application?" you are not eligible to apply for the Gentex Employee Hardship Fund Grant Program at this time. Please contact Yadah V. Ramirez at (616) 994-8862 with any questions.

Contact Information

Form Preparer, if different than employee
Name of Person Completing Form

First NameLast Name
Relationship to Employee
Phone Number
Please enter a valid phone number.
Email
example@example.com

Eligibility

Employment Status
QUALIFYING EMPLOYMENT STATUSES
- Full Time is 100% FTE per Classification in Workday Profile.
- Part Time is 50%- 99.99% FTE Classification in Workday Profile
- Approved Medical Leave and Approved Leave of Absence is leave approved from the LOA Department. Leave shall not be greater than 1 year to be eligible.
- A Spouse is defined as a person who is legally married to an employee under the laws of the state where the employee works and resides. The term “spouse” does not include a common law spouse or a spouse who is legally separated (e.g., an order of separate maintenance has been entered with the court) or divorced from the employee. Moving out and filing for divorce is not legal separation for this purpose.
- A Qualifying Household Member is defined as an immediate or extended family member of the employee by blood, marriage, or adoption who permanently resides in the same residence as the employee and either (a) contributes to at least half of the household's financial income or (b) receives at least half of their support from the household's primary wage earner. A Qualifying Household Member includes, but is not limited to, the Spouse and dependent child(ren) of the employee.
Employment must be in the United States.
Date*

MonthDayYear
Date
Job Title*
Employment Status*

Full timePart timeOn approved medical leaveOn approved leave of absenceSpouse, dependent child, or other qualifying household member of employee
Location of Employment*

United StatesOutside the United States
Supervisor*

First NameLast Name

Eligibility

Previous Applications and Grants
Have you applied for a Gentex Employee Hardship Fund grant before?*

YesNo
Have you applied for a Gentex Employee Hardship Fund grant paid on your behalf before?*

YesNo

Eligibility

Household Information
Number of Adults Living in Household?*
Number of Children Under 18 Living in Household*
Are you the only person contributing to the household income?*

YesNo
If other people contribute to the household income, please list who they are, if they work part-time or full-time, and what is their annual income or hourly wage. If there are other adults in the household, but they do not contribute to the household income, please explain why. If you are the only person in your household please type "N/A".*

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

Applications and supporting documentation will be treated in a confidential manner by CFHZ; however non-identifying statistical information will be reported to Gentex on a periodic basis.

By signing below the applicant certifies that all information is truthful and correct to the best of their knowledge.

By signing below the applicant gives permission for the service provider(s) and insurance company(ies) to share information with CFHZ and for CFHZ to contact them.
Full Name*
Signature*

Clear
Date*

MonthDayYear
Date
The CFHZ Program Officer will contact you after a determination regarding your eligibility based on your employment status, previous applications and grants, and the Qualifying Event has been made.

If you are eligible to move forward in the application process, you will be asked to provide information to demonstrate your unexpected financial hardship and immediate financial need including:
- household monthly income
- household adjusted gross income (AGI) from most recent tax return(s)
- itemization of assets and monthly expenses
- insurance coverage
- any other sources of aid
Should be Empty:

Gentex Employee Hardship Fund Grant Application Part 1

Contact Information

Contact Information

Eligibility

Eligibility

Eligibility

Eligibility

Eligibility

Certification and Permission