Hermann Area District Hospital Co-worker Crisis Fund Application

HADH 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. If this Application is not fully completed, it will be returned to you. 2. Attach the two most recent copies of your Hermann Area District Hosipital 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 documentation attests 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

Coworker ID

Name

Coworker First NameCoworker Last Name

Preferred contact number(home/cell/work)

Best time to be reached

Personal email address

example@example.com

Address

Street Address Line 2

CityStateZip

TitleDepartment

Hours worked per week

Date of Hire

Date

Spouse Name

Spouse First NameSpouse Last Name

Spouse Employment

Spouse hours worked per week

Other Members of the Household:

Name

Relationship

Employed

Name

Age

Relationship

Employed

Name

Age

Relationship

Employed

Name

Age

Relationship

Employed

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 HADH Co-worker Crisis Fund help most?

Please list other sources of assistance you have tried

Checking Account Balance

Savings Account Balance

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

	Model	Year	Payment
1
2
3

Monthly Income:

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

Child Support

AFDC: (Assistance to families with dependent children)

SSI Disability

Social Security

Unemployment

Other

Other Household Family Member Income

House Payment/Rent If you rent, do you have renters' insurance? Auto Payment

Type a question

	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
Land Line
Cell

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

	Name	Current Balance	Monthly Payments
1
2
3
4
5

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

Date

FINANCIALSTATEMENT

MONTHLY EXPENSES