BSRO ASSOCIATE ASSISTANCE FUND APPLICATION

BSRO ASSOCIATE ASSISTANCE FUND APPLICATION
Please complete the entire application. Incomplete applications will be automatically denied and returned to you. Note: Due to IRS regulations, if your work status is not currently "active" we are prohibited from reviewing your application at this time. Individuals off work due to accident or sickness are not eligible while they are off work.
Name

First NameLast Name
UID #:
Email Address:
example@example.com
Home Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone #:
Format: (000) 000-0000.
Authorization and Acknowledgement
Please read and sign: Release of information: I give the AAF authorization to check my credit record and to receive and exchange information about my credit history. I further authorize my payroll office to release information pertaining to my leave and earnings statement and work status, and authorize the AAF to receive information from my supervisor as deemed necessary. By signing below, I have fully and truthfully completed this application. To the best of my knowledge the information on this application is complete and accurate. By signing this application, I grant permission to the AAF to make all inquiries they deem necessary to verify the accuracy of the statements I made on this application. The AAF will take all reasonable steps to protect my privacy. The AAF will not tolerate fraud, deceit or concealment regarding the information on this application or obtained during the information gathering process. If the AAF determines that any such behaviors have occurred, it may deny any current or pending application and may not provide future assistance. For BSRO teammates, any such behavior is considered a violation of the BSRO code of business conduct and will be subject to the consequences as set out in the policy guidelines. Information provided to the AAF is kept confidential except as required by law. The AAF may decline any request for assistance at its sole and entire discretion.
Please confirm you are eligible for assistance from The AAF by confirming the following (If either of these statement are not true, please STOP and reach out to your Human Resource Business Partner or Aetna Resources for Living:
Printed Name
Signature of Teammate Applying
Today's Date (Date of Application)

MonthDayYear
Date

Rows	Amount ($)
Net Pay of Applicant (amount on paycheck)
Net pay of Spouse (amount on paycheck)
Disability or Retirement Income
Investment Income
Other Income (Child Support/Unemployment/Household Member Income)
TOTAL Monthly Income

Rows	Amount ($)
Checking Account Balance
Savings Account Balance
401K Balance
TOTAL ASSETS

Rows	Yes	No
In the process of filing Bankruptcy?
Filed for Bankruptcy in last 12 months?
Currently paying on a Bankruptcy?

Rows	Information
Apartment Name/Owner
Contact Name
Contact' Phone Number
Monthly Rental Payment
Renter's Insurance Payment

Institutional Creditors
Please list all Loans, Credit Cards, Bankruptcy Payments, Credit Counseling payments and any other Monthly Payments (attach additional page if necessary)

Rows	Name	Balance	Monthly Payment	Loan Type
Creditor
Creditor
Creditor
Creditor
Creditor

Monthly Household Expenses

Expenses (enter "0" if not applicable)

Rows	Monthly Amount ($)
Rent/Mortgage
Gas (House)
Electric
Water
Trash
Food
Transportation (Fuel/Bus/Train fare)
Home Phone
Mobile Phone #1
Mobile Phone #2
Internet Service
Cable/Dish/Streaming Service
Clothing/Laundry
Child Care
Total Credit Cards
Car/Vehicle Payments # 1
Car/Vehicle Payments # 2
Car/Vehicle Payments # 3
Motorcycle/ATV Payments
Boat/Camper Payment
Car Insurance
HOA
Other

Monthly Cash Flow

Rows	($) Amount
Total Monthly Net Income (Page 2)
Subtract Total Monthly Expenses
Total Monthly Cash Flow

Explanation of Emergency Situation
Amount you are requesting from the AAF:
Describe your need:
How did this need occur and how is the need causing a hardship to you/your family?
What else have you done to try to meet this need (e.g., other resources) and what was the outcome of those attempts?
Is any portion of your request covered by any insurance policies? (Explain)

File Upload (Attach most recent pay stub)

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IMPORTANT NOTE: Please attach additional information relevant to your hardship such as copies of bills, statements, court orders and receipts which you're asking for assistance with and that will support your application.
File Upload (Supporting Documents)

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File Upload (Supporting Documents)

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File Upload (Supporting Documents)

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File Upload (Supporting Documents)

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Should be Empty:

Rows	First and Last Name	Relationship	Age	Current Address
1
2
3
4
5
6
7
8

Rows	Amount/Balance	Monthly Payment
Primary Mortgage
Secondary Mortgage (if applicable)
Homeowner's Insurance
Real Estate Property Taxes

BSRO ASSOCIATE ASSISTANCE FUND APPLICATION

Authorization and Acknowledgement

Housing Information

Institutional Creditors

Monthly Household Expenses

Explanation of Emergency Situation

IMPORTANT NOTE: Please attach additional information relevant to your hardship such as copies of bills, statements, court orders and receipts which you're asking for assistance with and that will support your application.