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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)*
Employee ID (Encompass only):
Position (enter your job title):*
Date of Hire:*

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.

Select Hardship Category:*
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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