Employee Hardship Fund Application

Disaster Information
Date of Disaster*
Name of Declared Disaster*
Description of Disaster: Please provide a brief description of the disaster and its impact on you*

Financial Assistance Request
Amount of Grant Requested (up to $2,500): *
(Grant amounts are subject to availability and verification of need.)
Please specify how the funds will be used to reimburse or pay reasonable personal expenses caused by the above-referenced disaster, e.g., temporary housing, medical expenses, repairs, etc.:*
NOTE: Grant payments are treated as nontaxable disaster relief payments; however, the employee is responsible for any taxes found owing on the employee’s portion of the grant payment, as applicable.

Supporting Documentation
Please attach any relevant documents, such as photos, receipts, or official reports.

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Proof of Residency
Please provide proof of residency, such as an energy bill, the bill does not need to contain the bill amount, however proof must contain your name and address. Please see above example.*

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Public Records

This document and other records relating to the Employee Hardship Assistance Program may be subject to Chapter 119, Florida Statutes, and disclosure as a public record.
Acknowledgment and Signature

I hereby declare that the information provided is true and accurate to the best of my knowledge. I understand that any false information may result in the denial of my application.
Signature*

Clear
Date*

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The Employee Hardship Assistance Program is administered by the USF Foundation. Submissions are confidential and will be treated as confidential and may be exempt under the Florida public records law as provided in Section 1004.28.
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Employee Information