Employee Emergency Fund

Application Form

The purpose of the Employee Emergency Fund (EEF) is to provide limited financial assistance for employees of Novant Health Southern Piedmont Region. The funds are to be used as a last resort for basic needs (i.e. food, clothing and shelter) when all other resources fail. Due to the high level of need the amount requested can not exceed $300. It is short-term help for emergencies.

To be eligible, one must :

• Be a Novant Health Southern Piedmont employee, including full-time, part-time, PRN employees and
• Novant corporate employees based in the SP
• Have completed their introductory period
• Have not received money from the fund in the last 12 months
• Have no one else in the immediate family who has received money from the fund in the past 12 months
  

Employees need to:

• Complete the application
• Bring a recent pay stub with you 
• Bring a bill or letter stating how much you owe and to whom
• Submit a letter about your need
• You are also welcome to bring any other documentation which helps support your case for requesting emergency funds. 
  

All decisions of the EEF Review Committee are final. The EEF is made possible through gifts from the Presbyterian Foundation and the Presbyterian Auxiliary. Only a limited amount of money is available. Upon depletion of funds, requests will not be reviewed until fundraising activity restores the Fund.

Applying for Funding:

In addition to the above information please submit a  letter, not to exceed one page.  Include as much detail as possible in the attached application.

The letter should include the following:

The committee meets on the 2^nd and 4^th Wednesdays to review all information from your EAP counselor. An application that does not provide specific needs and/or an incomplete application will not be processed.  Request for funding are limited to one request each year.

PLEASE NOTE: The invitation to submit an application does not guarantee selection to receive financial assistance.

For additional information regarding the approach by which the committee will review this application, please refer to the Code of Ethics Policy located on the intranet.
 

Please print the following information:

Date:________________ Date of Employment(including year):_____________________

Name (First, Middle, Last): _________________________________________________

Home Address [Street/City/State/Zip]: ____________________________________________________________________

Home Phone:______________________ Social Security #: _______-_______-________

Novant Health Department:_____________________ Shift:______________ Work Extension:_____________ 
Status: FT PT PRN

Have you or anyone in your immediate family received EEF funds in the past?  Yes  No
If yes, who and on what date? ________________________

Number in household:_________________________

Ages of Children in household:___________________

How long have you worked with EAP? ____________________

Names of those in household [Age/ Occupation or Student]:

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

4.____________________________________________________________________________

5.____________________________________________________________________________

Specific reason for requesting assistance: ___________________________________________
______________________________________________________________________________

List any other support already received and /or pledged.  Include sources with contact information and amounts.

______________________________________________________________________
______________________________________________________________________

Family ____ Friends ____ Crisis Assistance ____ Loaves & Fishes____
Consumer Credit Counseling _____ Church_____

Income:

How many PTO hours do you have? _______ Sick bank hours? _______

Have you sold PTO this year?  ___ yes ____no  If yes, how many hours were sold___________

Hourly wage __________________    Net Monthly income ________________

Spouse/significant other net income _________________

Total net monthly household income ________________(from all sources)

Savings _________________

Do you own your home? _____yes _____no If yes, how long? _________

Do you rent your home? ____yes ____no

Do you live in an apartment____ condo ______ other________

How long have you lived in your above arrangements? _____________

Name and phone number for landlord_______________________________

Monthly Bills:

Rent/Mortgage ________________________ Other____________________________

Utilities _______________________________________________________________

Car__________________________________________________________________

Car Insurance __________________________________________________________

Phone _________________________________________________________________

Other _________________________________________________________________

How much financial assistance would help with your current emergency?
[cannot exceed $300] ______________________

NOTE: Vouchers will be issued whenever possible. Checks will be made payable only to a community organization, agency or third party.

May we contact your supervisor if needed?  Yes     No

If yes: Name ________________________________ Extension _________________

Human Resources will be contacted to verify date of employment and probationary status.

Applicant Signature ____________________________________Date ________________

Please contact the Employee Assistance Program at 384-7475 to set up an appointment to complete the application.

FOR OFFICE USE ONLY

EAP Counselor Comments:

Review Committee Action: