Aid Application, Income, Expense and Debt Verfication_Compassionate Caregivers Fund - Flipbook - Page 1
Compassionate Caregivers Fund
Aid Application
Please print out this form, complete and send to Home Office Human Resources, marked Confidential.
Associate Name:
Date:
Address:
Social Security Number (for ID purposes only):
Community:
Home Phone:
Work Phone:
Current Job/Position:
Gross Salary:
Please check one
Please check one
Hourly
Part-Time/Per Diem
Salary
Full-Time
Amount Requested: $
Please answer the following questions completely. All information given will be confidential.
Financial disclosure is required. (Attached additional information to the application if needed)
1. What is the purpose of this request? Describe the circumstances that led to the emergency.
2. How will the Fund Aid be spent? Please be specific.
