MSB HELPing Hands Fund Application

This fund is designed to provide immediate financial assistance to active MidSouth Bank employees who have experienced financial hardships due to an emergency situation that is beyond their control.

Please note the amount granted to an applicant cannot exceed the available fund balance at the time of the application.
A red asterisk (*) indicates a required field.
Select a Choice:
Employee Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number:

Area CodePhone Number
E-mail:

Confirmation Email
Physical Address at time of disaster:

Street Address

Address Line 2

CityState

Zip Code
Please select ALL items that were damaged as a result of the incident:

Other
Your primary residence / property that was affected by the disaster is / was:
Please select the type of insurance coverage you had prior to the disaster event:
Current Employment Status:
Total household income level:
Please estimate your out of pocket expenses incurred or to be incurred from damages, losses and expenditures detailed in the application that are NOT expected to be covered by insurance, government assistance, FEMA, or from other sources. Please exclude the costs associated with nonessential, luxury or decorative items and services:
Ex: $1,000
Additional Comments regarding the impact, physical damage or financial need:
Please upload up to 6 pictures of your loss/damage:

Upload a File

Cancelof
I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process.
Address for which the grant should be mailed to, if approved:

Street Address

Street Address Line 2

CityState

Zip Code
Should be Empty: