Anthem Employee Resource Fund Grant Application

Eligibility Confirmation
Currently employed by Anthem Memory Care
Completed at least 90 days of employment(add disclaimer)
Not on a leave of absence and have not been terminated
I am an Anthem employee, not a volunteer, vendor, contractor, or agency staff member
In good standing, including attendance, written warnings, and performance evaluations if applicable
Have not received an ERF grant within the past rolling 12 months

Applicant Certification and Authorization
I certify that the information in this application is true and complete to the best of my knowledge
I certify that the hardship is unforeseen and unavoidable, and is not ongoing or predictable financial strain, a lifestyle choice, a personal legal issue or fine, a scheduling conflict, or voluntary unpaid time off
I authorize SHORE to review and verify the information and documentation submitted with this application
I understand that submitting an application does not guarantee approval or a specific grant amount
I understand that, if approved, the grant will be paid directly to me and is a gift, not a loan, and does not need to be repaid
I understand that additional information may be requested to complete the review of my application
I understand that SHORE may contact me or my employer to verify details related to this request
Signature
Applicant Signature
Full name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: