« Colleague Emergency Assistance Fund

Colleague Emergency Assistance Fund

Application for HSHS Colleagues

Date

Colleague Name

Colleague ID

Six digit number on back of colleague ID badge

Preferred Email

Home Address

City

State

Zip Code

Home Phone Number

Work Phone Number

Select your Ministry

Department

Grant Amount Requested

Up to $500

Date When Payment is Needed

Please note: Payments can take up to 7-10 business days to be processed and received once application is approved.

Details of Event/Need

Please describe the event that is causing your financial need. Please be as detailed as possible, including expenses directly related to the event and other avenues of support you have explored.

Make Payment To

Please provide vendor name, address and telephone.

Upload Documentation

Please select a file

Please attach copies of bill(s) or invoice(s) needing payment. Your payment will be expedited if you provide an IRS Form W-9 from the vendor(s). Get form here: https://www.irs.gov/pub/irs-pdf/fw9.pdf

Upload 2nd Document

Please select a file

Upload 3rd Document

Please select a file

Prior Applications?

Yes No

Do you have prior applications for assistance since 1/1/2021?

Number of previous applications

Approximate date of last application

Acknowledgement

I have read and understand the Colleague Emergency Fund Eligibility Guidelines

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By checking this box, you attest that the information you have provided is true and correct.