• Tennessee Farmers Cooperative Employee Assistance Program (EAP)

  • Employee Assistance Application

  • Confidential – For EAP Committee Review Only

    Thank you for submitting an application for assistance through the Tennessee Farmers Cooperative Employee Assistance Program (EAP). The purpose of this program is to provide financial assistance to eligible employees experiencing an unexpected financial hardship or emergency.

    Submission of an application does not guarantee approval or receipt of assistance. All requests are reviewed based on program eligibility requirements, supporting documentation, available funds, and the guidelines established by the Tennessee Farmers Cooperative Foundation Board of Directors.

    Approved assistance will not be paid directly to the employee. Payments will be made directly to approved vendors or service providers on behalf of the employee.

  • SECTION 1: EMPLOYEE INFORMATION

  • Employer:
  • Date of Hire:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Contact Information:
  • Format: (000) 000-0000.

  • SECTION 2: TYPE OF ASSISTANCE REQUESTED

  • Please select the category that best describes your request:

  • SECTION 3: DESCRIPTION OF FINANCIAL HARDSHIP

  • Date the hardship or qualifying event occurred:
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECTION 4: ASSISTANCE REQUEST DETAILS

  • Have you previously received assistance through the EAP?
  • Requested assistance will be used for:

  • SECTION 5: VENDOR/SERVICE PROVIDER INFORMATION

  • Approved assistance payments will be made directly to the vendor or service provider.
  • Format: (000) 000-0000.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • SECTION 6: SUPPORTING DOCUMENTATION CHECKLIST

  • Please provide documentation supporting your request. Applications may be delayed if required documentation is not provided.

    Required or applicable documentation may include:
  • Required or applicable documentation checklist:
  • Please note: Screenshots and handwritten receipts are not considered sufficient documentation.

  • SECTION 7: OTHER AVAILABLE RESOURCES

  • Have you received or applied for assistance from another organization related to this hardship?
  • Have insurance benefits, government assistance, or other resources been applied?

  • SECTION 8: EMPLOYEE CERTIFICATION AND AUTHORIZATION

  • I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that providing false or misleading information may result in denial of assistance and may result in disciplinary action.

    I understand that:

    • Submission of this application does not guarantee approval or assistance.
    • Assistance decisions are made by the Tennessee Farmers Cooperative Employee Assistance Program Committee based on established guidelines and available funds.
    • Approved assistance will be paid directly to an approved vendor or service provider and will not be distributed directly to me.
    • Additional documentation may be requested during the review process.
    • Information related to my application will be kept confidential and shared only with individuals necessary for eligibility verification, review, approval, and payment processing.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: