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Employee Emergency Hardship Fund Application

Encompass Cares Employee Emergency Relief Fund Online Application

Complete entire application and provide as much detail regarding your circumstance as possible

Name:*
Address:*
Personal Phone*
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Work Phone*
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E-mail Address*
Work Location (enter the location of the Encompass office where you are employed)*

NOTE: Incomplete requests will not be processed. Supporting documentation and signatures are required and must be submitted with the application (examples are documentation include: eviction/foreclosure notifications, past due utilities, policy/fire report, Invoice of funeral expenses, doctor’s note and other related documentation). Documentation must be on letterhead or statement of owned party.

1. Please describe your emergency and circumstances in detail (including all dates)*
2. Are you currently, or have you within the past 12 months, received any financial assistance from the following sources: Worker's Compensation, short-term disability, long-term disability, insurance, state/federal agencies, non-profit agencies, fundraising efforts, or any other entity that is assisting you with your financial hardship? If so, please list the amount of money received and frequency of assistance.*
Total $ Received
Frequency of Assistance
3. Amount of financial assistance requested from Encompass Cares*
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