Bluemont Cares Fund Application

Bluemont Cares Fund Application
The first step in requesting financial assistance from the BCF is to read the program guidelines. If you feel your request falls within the guidelines, complete and return this confidential application. Directions about how to send in this form are at the end of the application. Once received, the Human Resources Department will contact you within two business days.
Initial Eligibility for BCF Consideration
1. Team members must be in good standing with Bluemont in order to meet initial eligibility requirements for BCF Assistance, Generally speaking, this means that the applicant's current performance must be at a "meets expectations" level or higher. By signing this application, you agree and understand that we may obtain employment information in order to consider your application for BCF assistance.
2. You have not received any other grant(s) from the BCF within the last twelve months.
3. Payroll garnishments may affect your eligibility for a grant.
If your employment status meets initial eligibility guidelines, we will review the information you provide in response to thefollowing questions - including personal information, financial data and details about the specific event that is triggering this request - to make a determination on your BCF application. This information will be kept confidential and will not be usedfor any purpose other than in conjunction with this application for BCF benefits.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work/Store Phone
Please enter a valid phone number.Format: (000) 000-0000.
Store Name or Department*
Manager Name*
Enter your General Manager's name for Team Members in a store. For Bakery, Central Office and Field Services, enter your Direct Supervisor's name.
Manager's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Most Recent Hire Date

MonthDayYear
Date
Current Situation
1. Please describe the current financial need and provide details about the unexpected circumstances that led to this situation. Include specific events, challenges, or expenses that have contributed to your need for assistance:*
2. Date of Occurrence*

MonthDayYear
Date
REQUIRED -
Provide supporting documentation when applicable. Documentation may include but is not limited to:
- Medical payment plan
- Police Report
- Eviction Notice
- If applying for housing assistance, a rental agreement or written statement from a landlord indicating move in date, deposit required, and ongoing monthly rent amount will be required prior to assistance grant.
Supporting Documentation File Upload

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3. Do you have other resources available to you? (e.g. Life insurance, renter's, auto or homeowner's insurance, health coverage including Medicaid, and community services, etc.)*
4. What is the amount you are requesting from the BCF? *
5. Specifically, how do you plan to use these funds?*
Financial Information

Please complete the following to the best of your ability so that we can better understand your financial need.
YourselfA Family MemberA Combination
YesNo
If yes, please explain:
3. On average, how much do you bring home (after all deductions), from each Bluemont check? *
How much do you bring home per week in CASH tips in addition to your paycheck?*
Type n/a if not applicable
YesNo
If not, please detail other sources and income as follows:
Spouse or domestic partner monthly income:*
Type n/a if not applicable
Other employment/2nd job (Estimate monthly income):*
Type n/a if not applicable
Child Support or Community Aid:*
Type n/a if not applicable
Any other members of same household with income:*
Type n/a if not applicable
YesNo
If yes, what is the balance? *
Type n/a if not applicable
6. Please detail your regular monthly expenses:
Rent/Mortgage:*
Combined utilities:*
Car insurance:*
Gasoline:*
Cell phone:*
Groceries:*
Childcare:*
Type n/a if not applicable
Other:*
Type n/a if not applicable
Other Information
1. How did you find out about the BCF? *
2. Have you ever applied for BCF assistance before?*
If so, when and what was the amount? *
Acknowledgment
I represent and acknowledge that the above information is true and accurate to the best of my knowledge and has been provided in conjunction with my application for BCF benefits. I understand the BCF Guidelines and I also understand that the allocation of BCFs is determined by priority of the situation, the availability of funds and the sole discretion of the BCF staff.
Yes
The Human Resources Department will contact you within two business days of receiving the application for further information. If you have questions, please email bluemontcares@bluemontgroup.net.
Should be Empty:

Bluemont Cares Fund Application

Initial Eligibility for BCF Consideration

Current Situation

Financial Information

6. Please detail your regular monthly expenses:

Other Information

Acknowledgment