Hardship Fund Application

Hardship Fund Application
- Must be a Member in good standing (initiation fee paid in full and dues up to date);
- Have suffered an emergency or catastrophic situation that has caused temporary, sudden and non-recurring financial shortfall (e.g., natural disaster, immediate family crisis, acute illness or injury;
- Are unable to meet immediate, essential expenses.
MEMBER'S NAME*
EMPLOYER*
ADDRESS*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
EMAIL*
example@example.com
BEST CONTACT PHONE*
Format: (000) 000-0000.
WORK PHONE
Format: (000) 000-0000.
I HEREBY STATE THAT THE INFORMATION HEREIN PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE*

Clear
DATE*

MonthDayYear
Date
1. Fill-in all requests for information and sign the Application Form.

2. Include an explanation of the emergent or catastrophic situation causing the need for financial assistance.

3. Include a complete bill or statement of the creditor(s) to be paid with full creditor information (e.g., utility bill, rental agreement, bill from auto shop, car payment statement). A screenshot of a balance due from an online portal, for example, will not be accepted.

4. Please list the exact amount of assistance needed and the vendor or creditor that the amount should be sent to. Awards are paid directly to the creditor/vendor by check.
YesNoNot sure
YesNoNot sure
If yes, please explain (including info about the emergency/catastrophic situation, how it has impacted you financially, and how it is temporary and non-recurring).*
YesNo
Utilities (electric/water/gas or internet/cable/phone)RentCar Payment/Car RepairsMedical/Dental/Veterinary Bills
Complete bill or statement*

Cancelof
Please list each individual expense that you are seeking assistance for in order of urgency and need (these ammounts should not total more than $350).

If including estimates or costs for service(s), please be sure the paperwork is as detailed about the expense and need as possible. Include the full creditor information, including account number to submit payment. NOTE: Vendors/creditors must accept checks.
Name and Address of the Vendor/Creditor we should make check payable to:*
FIRST EXPENSE
Account #, Reference #, Invoice #*
FIRST EXPENSE
Exact Dollar Amount Needed ($USD)*
FIRST EXPENSE
Name and Address of the Vendor/Creditor we should make check payable to:
(ADDITIONAL) SECOND EXPENSE
Account #, Reference #, Invoice #
(ADDITIONAL) SECOND EXPENSE
Exact Dollar Amount Needed ($USD)
(ADDITIONAL) SECOND EXPENSE
Name and Address of the Vendor/Creditor we should make check payable to:
(ADDITIONAL) THIRD EXPENSE
Account #, Reference #, Invoice #
(ADDITIONAL) THIRD EXPENSE
Exact Dollar Amount Needed ($USD)
(ADDITIONAL) THIRD EXPENSE
Total Amount Requested*
Should be Empty:

Hardship Fund Application

Please list each individual expense that you are seeking assistance for in order of urgency and need (these ammounts should not total more than $350).