NAIFA Family Response Fund Application

The NAIFA Family Response Fund has been activated to provide immediate financial assistance to NAIFA members who are experiencing financial hardship as a result of the COVID-19 pandemic.

Grants will be considered for those members who incur out-of-pocket medical expenses, unanticipated funeral expenses or other extraordinary COVID-19 related expenses. We will consider legal dependents as they are defined by the IRS - persons other than the taxpayer or spouse who entitles the taxpayer to claim a dependency exemption.

Grants will not be issued for lost wages and members must be in good standing of NAIFA to be eligible for financial assistance.
Personal Information
A red asterisk (*) indicates a required field.
Select a Choice:
Member Name: *

First Name Last Name
Member ID: *
Phone Number: *

Area Code Phone Number
E-mail: *
Are you a member of NAIFA and in good standing with the organization? *

Yes No
The NAIFA Family Response Fund can only provide assistance to those NAIFA members who are current and in good standing with the organization. Please contact NAIFA for more information about your membership status.
Are you applying due to lost wages? *

Yes No
Per IRS rules, the NAIFA Family Response Fund cannot provide financial assistance for loss of income or lost wages.
Name of Business: *

Parish/County: *
Describe Your Situation
Which qualifying situation caused the financial hardship? (Hover over text to see more details about the options below and choose the one that best fits your circumstances) *

Natural Disaster Medical Emergency Death Incident Other Extraordinary COVID19 Related Expenses
Type of incident (ex: hurricane, type of injury, name of illness, etc.) *
Date of incident (must be subsequent to 2-1-20 and within 60 days of incident): *

Month Day Year
Date
Describe what has happened to cause your financial hardship and your immediate needs: *
Estimated dollar amount of IMMEDIATE relief needed: *
Additional Financial Information
Total household income level (should include spouse, partner, etc.) *
Your primary residence is: *

Owned by you Rented by you Neither owned nor rented by you
Please select the type(s) of insurance coverage you had prior to the event: *

Homeowner's Insurance Renter's Insurance Medical Insurance None of the Above
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
Attach Supporting Documentation

Please attach any pictures, invoices, insurance documents, repair estimates, death certificates, medical/pharmaceutical bills, proof of home ownership documents, etc. that will help us validate your claim. Providing these upfront will significantly speed up the evaluation process.
Upload up to 8 files related to your qualifying situation:

Upload a File

Cancel of
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. *

Yes No

Should be Empty:

Street Address
Street Address Line 2
City	State
Zip Code	Country

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Personal Information

The NAIFA Family Response Fund can only provide assistance to those NAIFA members who are current and in good standing with the organization. Please contact NAIFA for more information about your membership status.

Per IRS rules, the NAIFA Family Response Fund cannot provide financial assistance for loss of income or lost wages.

Describe Your Situation

Additional Financial Information

Attach Supporting Documentation