Fillable Printable Family Dollar Job Application Form for Financial Assistant
Fillable Printable Family Dollar Job Application Form for Financial Assistant
Family Dollar Job Application Form for Financial Assistant
GRANT APPLICATION FOR FINANCIAL ASSISTANCE
5
Section I: Team Member Information (Required)
Last Name:
First Name:
Middle Initial:
Team Member ID:
Hire Date:
# Hours Scheduled:
Job Title:
Department:
Manager’s Name:
Manager’s Phone:
Work Address:
City:
County:
State:
ZIP:
Permanent Home Street Address:
Rent Own
City:
County:
State:
ZIP:
Home Telephone:
Cellular Telephone:
Email:
If, because of the catastrophe, you cannot receive mail at your home address, provide another mailing address
below:
Marital Status Single Married Divorced/Separated Domestic Partner
Family Members (spouse and dependents only) Relationship Age Family Dollar Team Member
Yes No
Yes No
Yes No
Yes No
Have you applied before for FamilyHope
assistance?
Yes No If YES, date applied
(mm/dd/yy):
Section II: Other Financial Assistance (Required)
Applicants must demonstrate that they have exhausted all other financial resources to meet their immediate
needs prior to applying for FamilyHope assistance. Please list details of financial assistance applied for and
received. Do not use abbreviations.
Sought Assistance (Check those that apply) Results Date Amounts
Homeowner’s or renter’s insurance
$
Auto insurance
$
Medical insurance
$
Social service organization, e.g., Red
Cross, United Way, Crisis Assistance,
Goodwill, state or local government agency
$
Federal Emergency Mgmt. (FEMA)
$
Religious organization
$
Family members
$
Loan program (e.g., 401K, bank,
personal)
$
Team Member benefits
$
Other:
$
Total
$
GRANT APPLICATION FOR FINANCIAL ASSISTANCE
6
Section III: Disaster Relief Assistance (Required for Disaster Requests Only)
Instructions
1.
Check the type of disaster that has caused a financial hardship.
2.
Provide supporting documents with the application.
Date of the Disaster:
Name of Event:
Disaster (Please check) List of Qualifying Expenses
Act of nature/non-presidentially
declared disaster (e.g., flood, hurricane,
tornado, ice storm, wild fire, earthquake)
Please specify:
House fire
Presidentially-declared natural disaster
Disaster resulting from terroristic or military
action
Disaster resulting from an accident on a common
carrier
Any event determined by the U.S. Secretary of the
Treasury to be of a catastrophic nature
Food
Clothing
Housing
Essential household utilities—electric, gas, water,
sewer
Evacuation expenses
Transportation (vehicle repairs, assistance for
replacement, etc.)
Home repairs/essential appliances and furnishings
[Security deposits for new property (only if unable to
inhabit existing home due to hardship event)]
Area of Home or Items Damaged or
Destroyed
(Primary residence only)
Qualifying Expense
(Please choose from the list above)
Estimated Value
Prior to Event
Amount
Requested
$
$
$
$
$
$
$ $
$ $
Total
$
Insurance
Yes No
Does the Team Member have insurance coverage to assist with the requested expenses?
Is the insurance company paying for the Team Member’s immediate needs?
Will insurance reimburse the Team Member for any out-of-pocket, essential living expenses?
Was the Team Member evacuated from his or her primary residence?
In the space provided, please tell us anything else that would help us understand your circumstances as a result of
the disaster:
GRANT APPLICATION FOR FINANCIAL ASSISTANCE
7
Section IV: Hardship Relief Assistance (Required for Hardship Requests Only)
Instructions
1.
Check the type of hardship event.
2.
Provide the required supporting documents.
3.
Please skip Section III of this application.
Date of the Emergency Hardship:
Emergency Hardship (Please check) List of Qualifying Expenses
Death of Family Dollar Team Member,
spouse/partner or dependent
Spouse/partner’s loss of employment/income
(temporary)
Unscheduled loss of child support
Unscheduled loss of alimony
Other (please specify):
Food
Clothing
Essential household utilities—electricity, gas, water,
sewer
Transportation (car payments, assistance with
replacement, etc.)
Mortgage payments, rent
Security deposits for new property (only if unable to
inhabit existing home due to hardship event)
Qualifying Expense
(Please choose from the list above)
Balance Due Prior to Event
(For past-due expenses only)
Amount Requested
$
$
$
$
$
$
$
$
$
$
Total
$
In the space provided, please tell us anything else that would help us understand your circumstances as a result of
your financial hardship:
GRANT APPLICATION FOR FINANCIAL ASSISTANCE
8
Section V: Personal Income (Required)
Please attach copies of most recent pay stubs for each wage earner.
Applicant’s annual gross salary or
wages (before deductions)
$
Prior to Qualifying
Event or Hardship
After Qualifying Event
or Hardship
Applicant’s spouse/partner’s annual
gross salary or wages (before deductions)
$
A.
Applicant’s average monthly net (after deductions)
$
$
B.
Applicant’ spouse/partner’s average monthly net (after
deductions)
$
$
C.
Applicant’s child support income per month
$ $
D. Applicant’s and/or spouse/partner’s social security
income per month
$ $
E.
Applicant’s and/or spouse/partner’s disability income per
month
$
$
F. Applicant’s and/or spouse/partner’s unemployment
income per month
$
$
G.
Applicant’s alimony per month
$
$
H.
Other income per month (please list):
$
$
Total Monthly Income (Items A-H)
$ $
Section VI: Monthly Expenses (Required for Hardship Requests Only)
Please list all current monthly expenses and debts (rent/mortgage; utilities (electricity, natural gas, oil, water,
phones, cable, internet); auto loans; insurance premiums; credit cards; medical bills; other loans; food; gas;
childcare; etc. If you are renting from a private landlord, you may be required to provide proof of rental
payments.
Monthly Expenses Monthly
Payment
Months
Past Due
Total
Balance
Due
Name of Creditor
Rent/mortgage
$ $
Electricity
$ $
Gas/oil for home
$ $
Water
$
$
Sewer/trash
$
$
Food
$
$
Transportation/car payment
$
$
Car insurance
$
$
Car fuel/gas
$
$
Medical expenses
$ $
Childcare/school tuition
$ $
Cell phone
$
$
Cable, internet, telephone
$
$
Other:
$
$
Other: $ $
Total
$
$
GRANT APPLICATION FOR FINANCIAL ASSISTANCE
9
Section VII: Vendor/Creditor Payments
In most cases, if the application for assistance is approved, the Foundation for the Carolinas will make grant
payments in the form of checks payable to the vendors to whom the Team Member owes payment(s). Please
provide a list of the vendor(s) who are to be paid if your application is approved. Attach appropriate
documentation, e.g., bills, eviction notices, invoices, estimates, etc. If you are renting from a private landlord,
you may be required to provide proof of rental payments. Please note that you are required to disclose any
familial relationships with vendors.
Creditor/vendor’s name
Creditor/vendor’s address
Creditor/vendor’s phone number/email/website address
Applicant’s account number
Relationship to creditor/vendor
Creditor/vendor’s name
Creditor/vendor’s address
Creditor/vendor’s phone number/email/website address
Applicant’s account number
Relationship to creditor/vendor
Creditor/vendor’s name
Creditor/vendor’s address
Creditor/vendor’s phone number/email/website address
Applicant’s account number
Relationship to creditor/vendor
Section VIII: Agreement and Authorization
I have done everything possible to help myself before applying for this grant. I certify that the information
provided in this grant application and any attachments to it is true and correct as of the date set forth below. I
authorize Family Dollar Benefits and Payroll to release information to the FFTC regarding this application.
My signature acknowledges and permits the Foundation for the Carolinas to verify all information.
Verification includes obtaining appropriate verifying information from my creditors and others referenced in
this application. Any intentional misrepresentation or material omission of information in making this
application or any attachments to it will result in the forfeiture of FamilyHope assistance now and in the
future. I understand that any such misrepresentation or omission by me constitutes fraud, which may be
reported to Family Dollar and for which I may be criminally liable.
Signature
(Required):
Date:
For FFTC Office Use Only
Date received
Date reviewed by FFTC
Committee
Application status Approved Denied Withdrawn
GE number Grant Amount $
