Schumacher Clinical Partners Employee Relief Fund Application

The Schumacher Clinical Partners Employee Relief Fund is designed to provide immediate financial assistance to employees who experience a financial hardship due to an emergency situation that is beyond their control during active employment.

Applicant must be a full-time, active Schumacher employee, employed by Schumacher for at least 90 days prior to the incident, in order to be eligible to apply. The applicant must also apply within 60 days of the incident to be considered for grant assistance.

Eligible applicants can receive a maximum of one grant per natural disaster incident per calendar year and one grant per hardship category per calendar year. 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.

Please note the amount granted to an applicant cannot exceed the available fund balance at the time of the application, and proper documentation is required to be considered for grant assistance.

A red asterisk (*) indicates a required field.

Select a Choice:

Employee Name: *

First Name Last Name

Date of Birth *

Last 4 digits of Social Security Number: *

Phone Number: *

- Area Code Phone Number

E-mail: *

Home Address: *

Street Address
Street Address Line 2
City	State
Zip Code	Country

Have you been employed with the company for at least 90 days? *

Yes No

Were you an active employee at the time of the incident? *

Yes No

Which qualifying situation caused the financial hardship? (Hover over text to see definitions of the options below and choose the one that best fits your circumstances) *

Natural Disaster Personal or medical emergency Death incident Home catastrophe

Type of incident (ex: tornado, fire, type of injury, name of illness, etc.) *

Date of incident (must be subsequent to 1/23/18 and within 60 days of incident): *

Date

Describe what has happened to cause your financial hardship and your immediate needs: *

Estimated dollar amount of immediate relief needed: *

Total household income level (should include spouse, partner, etc.): *

Do you own or rent your primary residence? *

Own Rent Neither

What is your monthly mortgage or rental payment for your primary residence? *

What is your monthly car payment(s)? *

What are you other monthly expenses? *

Number of legal dependents at time of incident: *

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: *

Are you requesting additional relief from other sources? (Ex: payments for medical or counseling services, temporary housing, etc.) *

Yes No

Can we share your story anonymously to help us build this program? (Your identity will not be disclosed) *

Yes No

Upload up to 6 pictures / files: *

Choose File

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

Personal Information

Describe Your Situation

Financial Information

Attach Supporting Documentation