OPEIU 8 - Hardship Fund Application Form

OPEIU Local 8 Hardship Fund Confidential Application for Assistance

Eligibility Guidelines for the Hardship Fund:

Must be a Member in good standing.
Have suffered an EMERGENCY or CATASTROPHIC situation that has caused temporary, sudden and non-recurring financial shortfall (e.g., natural disaster, immediate family crisis, acute illness or injury.)
Are unable to meet immediate, essential expenses.

Member's Name*

Employer*

Address*

Address

Street Address Line 2

CityState

Zip

Email Address*

example@example.com

Best Contact Phone #*

Work Phone #

I hereby state that the information herein provided is true and correct to the best of my knowledge.

Signature*

Date*

Date

Fill-in all requests for information and sign the Application Form.
Include all documentation of need that details the hardship request - written estimates, actual bills, receipts, rental agreement, mortgage payment book, invoices of service...
Requests for funds and all accompanying documentation of need should not exceed $350 - the maximum Hardship Fund award.
Please list the exact amount of assistance needed and the vendor or creditor that the amount should be sent to. (As a general rule, checks are not paid directly to applicants nor are gift cards awarded
If a request for assistance includes more than one (1) vendor or creditor, please itemize and prioritize the specific amount below. No more than a total of $350 dollars will be approved.

Please explain your EMERGENCY or CATASTROPHIC situation that has caused temporary sudden and nonrecurring financial shortfall (e.g., natural disaster immediate family crisis acute illness or injury):*

Please list each individual expense that you are seeking assistance for - in order of urgency and need (these amounts should not total more than $350):*

	Explanation of assistance needed	Name and Address of the Vendor / Creditor to Receive Payment	Exact Dollar Amount Needed
1
2
3

Total Amount Requested*

Documentation MUST be attached for each item listed above or the application WILL NOT be processed.

Examples: bills, invoices, leases, written estimates and/or receipts.

If submitting estimates or costs for service(s), please be sure the paperwork is as detailed about the expense and need as possible.

Upload documentation*