Hardship Application Step 1 of 7 14% Contact InformationYour Name(Required) First Last Date MM slash DD slash YYYY Position Held at Flagger ForceHome Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email Address(Required) Email Address Confirm Email Address Eligibility RequirementsDate of hire MM slash DD slash YYYY Have you received a final written warning within the past 60 days? Yes No How many dependents do you claim?Adults (18 and up)01234567891011121314151617181920Children (10-17)01234567891011121314151617181920Children (5-9)01234567891011121314151617181920Children (4 and under)01234567891011121314151617181920How many of these dependents do you claim on your federal taxes?01234567891011121314151617181920This hardship is an unexpected, unusual, and/or extraordinary event Yes No I have applied for assistance from the employee hardship grant program in the past Yes No Event date of that caused the current hardship MM slash DD slash YYYY List below all of the efforts you have taken to resolve this hardship, including other sources of financial or social aidPlease provide a brief description of the current event that caused this hardshipPlease describe below how the incident prevents you from meeting your financial obligations Request Bill Assistance Please list the bills that you would like the Employee Hardship Grant to consider paying on your behalf. These bills must have been caused by the incident described in the application. Please be sure that the total amount of these bills is equal to the total dollar amount you are requesting on the application. If you are requesting goods or services, please document the specific needs and expected costs below. Essential Need Provided(Required)Company Owed(Required)Amount Owed(Required)AddressName on AccountAccount NumberAdd billRemoveTotal need requestedDollar amount Cash (Assets)Cash on hand or checkingDollar amountSaving account balanceDollar amountOther accessible cashDollar amountTotalDollar amount Your monthly household incomeEmployee’s monthly gross wagesDollar amountSpouse’s monthly gross wagesDollar amountChild support receivedDollar amountDisability insuranceDollar amountSocial security income/pensionDollar amountTotalDollar amount Your monthly living expensesRent / MortgageDollar amountUtilities (phone, gas, electric, TV)Dollar amountFoodDollar amountChild support owedDollar amountMedicine / medical costsDollar amountChild/day care expensesDollar amountCar loansDollar amountGas/incidentals/otherDollar amountTotalDollar amount Upload DocumentsRequired documents: Copies of current bills or invoices listed below A letter or invoice from landlord with amount owed, or mortgage payment coupon A gift registry from a store like Target or Wal-Mart if you are seeking help to replace essential household items not covered by insurance Other documents to substantiate current amounts owed Upload files hereFileMax. file size: 128 MB. By submitting this application, I certify that the above information is correct and request that the Flagger Force Foundation reviews this application. I authorize FFF to obtain and/or verify all information necessary to process this application. Additionally, I understand that no employee is entitled to receive a grant, either by their employment, their history of contributions to the Foundation or because of any precedent inferred from a previously approved grant. I understand grants will not be made before an employee had demonstrated an immediate need.
