OLD - Hermann Area District Hospital Co-worker Crisis Fund Application

Hermann Area District Hospital Co-worker Crisis Fund Application
1. Complete Application in its entirety (below). After submission, a member of the local Crisis Fund Committee will contact you. Ifthis Application is not fully completed, it will be returned to you.

2. Attach the two most recent copies of your Hermann Area District Hospital payslips and if married or in a long-term relationship with a partner living with you, the two most recent copies of their payslips.

3. Attach copies of bills/statements for requested assistance (utilities, past due statements, etc.). This documentationattests to your crisis.

If you apply for assistance to the Hermann Area District Hospital Co-worker Crisis Fund more than one time/year, you may be requested to supply copies of your bank statements. The Fund is subject to audit by the IRS.
Date

MonthDayYear
Date
Co-worker ID
Name

Co-worker First NameCo-worker Last Name
Preferred contact number(home/cell/work)
Best time to be reached
Personal email address
example@example.com
Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Title/Department
Hours worked per week
Date of Hire

MonthDayYear
Date
Spouse Name

Spouse First NameSpouse Last Name
Spouse Employment
Spouse hours worked per week

Other Members of the Household:

Rows	Name	Age	Relationship	Employed
1
2
3
4

Do you have more members in the household?

YesNo
Have you ever applied to the Co-worker Crisis Fund?

YesNo
If Yes, when?
Please describe the crisis situation that made this request necessary.
How can the Hermann Area District Hospital Co-worker Crisis Fund help most?
Please list other sources of assistance you have tried.
FINANCIAL STATEMENT

Assets
Checking Account Balance
Savings Account Balance
Retirement Account(s) Balance
Do you own your own home?

YesNo

Vehicles (including autos, trucks, motorcycles, boats, farm machinery, etc.

Rows	Model	Year	Payment
1
2
3

Monthly Income:

Rows	Gross Monthly	Net Monthly
Co-worker from Hermann Area District Hospital
Co-worker income from second/other job
Spouse/Significant Other/Roomate income

Gross Monthly Net Monthly
Gross Monthly Net Monthly
Co-worker income from Hermann Area District Hospital
Please attach the most recent payslips of the above employment.

Cancelof
Family Monthly Income From:
Child Support
Social Security
SSI Disability
Unemployment
AFDC: (Assistance to families with dependent children)
Food Stamps
Other Household Family Member Income
Other
Total Monthly Income
MONTHLY EXPENSES
If you rent, do you have renters' insurance?

YesNo

Rows	Current	Past Due
House Payment/Rent
Auto Payment
Auto Fuel
Auto Insurance
Day Care
Other transportation expenses
Food/Groceries
TV/Cable/Satellite/Subscription Services
Electricity
Water/Sewer
Garbage
Gas
Internet
Telephone
Land Line
Cell

Credit Cards / Lines of Credit / Pay-Day Loans / Medical Bills/Student Loans: Current Monthly Name Payments Balance

Rows	Name	Current Balance	Monthly Payments
1
2
3
4
5

Rows	401K Loans	Current Balance	Monthly Payments	401K Loans	Current Balance	Monthly Payments
1
2

Total Monthly Expenses
Confidentiality Statement: Your application to the Hermann Area District Hospital Crisis Fund is confidential, and all information included in the application and obtained through interviews is held in confidence. This information will not be disclosed to anyone outside of the Crisis Fund Committee except in certain circumstances, including 1) by your written consent, 2) when law requires disclosure to state agencies when abuse or neglect of children or the elderly is suspected or observed, 3) when law requires disclosure to state agencies when imminent safety risks are present. Please note that providing false information in support of this request may result in disciplinary actions up to and including termination.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: