Carolinas Foundation Disaster Relief Grant

Name*

First NameLast Name

Credit Union*

PLEASE NOTE: You must be employed at a credit union in the Carolinas to be eligible for disaster assistance.

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Have you received a disaster relief grant from the Carolinas Foundation in the past year?*

YesNo

If yes, what is the total received in grant funding from the Carolinas Foundation?

Are you still displaced from your home because of the disaster?*

YesNo

Is this disaster causing financial hardship?*

YesNo

What are your current living arrangements? *

Length of Credit Union Employment/Volunteering/Membership:*

Job Title:*

What is the extent of your losses due to this disaster? Describe your losses & estimated dollar values below.

Your Home:*

Personal Belongings, etc:*

Total dollar amount of expenses not covered by insurance/FEMA/or other outside assistance:*

Amount of Grant Requested:*

The Carolinas Credit Union Foundation will make the payment on all approved grants up to the amount available.

Please read the following statement and sign below:

I,{name}, swear the provided information is true and all funds that I may receive will be used to aid me and or my family to recover from damages caused by this disaster.

I swear the provided information is true and all funds that I may receive will be used to aid me and /or my family. In its due diligence, if the Carolinas Credit Union Foundation discovers any information in this application to be materially untrue or fraudulent, I recognize that I may no longer expect this application to be treated confidentially and also recognize that information provided herein may be reported to the credit union. Payment of relief funds are intended to be a “qualified disaster relief payment” under IRC Section 139 and will not be taxable income to you nor subject to employment taxes or withholdings. However, you will be responsible for any taxes should the information you provided, and the fund relied upon to make its decision, is later found to be untrue or fraudulent.

My signature below authorizes the Carolinas Credit Union Foundation to obtain and/or verify all information necessary to process this application, and releases the credit union and the Carolinas Credit Union Foundation from any liability associated with the rejection of or funding of this application. In addition, I hereby agree to provide any requested documentation supporting the information provided.

Signature of Applicant*

Date*

Date

Routing Number for ACH Deposit*

Account Number for ACH Deposit*

Credit Union Name*

Please Check One*

CheckingSavings

Please indicate your credit union’s point of contact for employment verification. This can be your manager or someone in HR as directed by your credit union.

Credit Union Contact Name*

Credit Union Contact Email*

example@example.com