COVID-19 Relief - Employee Benevolent Fund Assistance Application

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* 1. Date

Date / Time

Date

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* 2. Employee Information

Name

Employee ID#

Street Address

City

State

Zip

Phone

Department

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* 3. Are you currently on a leave of absence?

Yes

No

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* 4. Are you on a final warning of a disciplinary action status?

Yes

No

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* 5. Do you have an unresolved Performance Improvement Plan?

Yes

No

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* 6. Please describe your current situation of need.

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* 7. Once determined that the application meets all guidelines and is able to be funded, payment will be issued through payroll for the amount determined by the Committee. Please note that taxes are taken from the payment so the actual amount received may be less. Depending on when the request is submitted, payments may not be made until the following bi-weekly payroll cycle.

I have read the Eligibility for Application Form