Grant Application -TEST Step 1 of 4 25% Are you completing this application on behalf of someone else?*YesNoYour Name* First Last Your Email* Your Preferred Phone*Preferred Phone Type*CellHomeWorkDo you currently work for JFR or SFM?*YesNoIf yes, what is the store number?*If not, how did you learn about the Jack's Family Fund?*What is your relationship to the applicant?*SupervisorCo-WorkerFriendSpouseChildParentGrandparentOtherIf other, please explain.*Section I: Applicant InformationThe applicant is the individual who is experiencing the hardship/ in need of assistance.Does the applicant currently work for JFR or SFM?*YesNoIf yes, what is the store number?*I understand that information contained within this application may be shared with my/the Applicant's supervisor, General Manager, Area Manager and/or Regional Director.*YesApplicant's Name* First Last Applicant's Email* Applicant's Preferred Phone Number*Phone Type*Cell PhoneHome PhoneWork PhoneHome Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Employment Status*Please select an optionFull-timePart-timeUnemployedRetiredDisabledOtherEmployer*Employer Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Postal Code Average number of hours per week*Salary/Hourly Wage*How did you learn about the Jack's Family Fund?*Are you currently enrolled as a student?*Please select an optionYes, Full-TimeYes, Part-timeNoWhere are you enrolled as a student?*How many people live in your household?*If you live alone, please enter "1"Please list names and ages of each person in household and explain their relationship to you.*Example: Myself, 30; Bob, 20, my roommate; Joe, 12, my son; Chris, 8, Roommate's son Does anyone other than yourself contribute to your household's income?*For example, do you receive food stamps, child support, or disability benefits? Does your spouse, roommate or child work and help pay the household bills? YesNoIf yes, please explain the source if income/support and the monthly amount.*For example: If you receive $250/month in food stamps and your son contributes $200/month from his paycheck, write "Food Stamps=$250; Son=$200"Did you receive an economic stimulus payment during in spring 2020?*YesNoWhy not?*Please explain your understanding as to why you did not receive the economic stimulus payment in 2020. Have you received a federal stimulus check in 2021?*On Dec. 29, 2020, the IRS began issuing a second round of Economic Impact Payments as part of the Coronavirus Response and Relief Supplemental Appropriations Act of 2021. Direct deposits began on 12/29/20 and paper checks/debit were scheduled to begin distribution on 12/30/20. Have you received this most recent stimulus payment yet?YesNoHow much was your stimulus payment and how will/did you spend it?*Please be as specific as possible. For example, "I received $1200. $400 went toward my electric bill and the remainder went toward my past-due rent." Section II: Request for Financial Assistance(Must be Completed)Hardship Category* COVID-19 Pandemic Fire Death Illness Accident Crime Natural Disaster Homeless Other What is your relationship to the deceased? He/she is your:*parentsiblingspousechildgrandparentgrandchildName of the deceased*If other, please explain*Being underemployed (not earning enough to cover your living expenses) or being unemployed are not considered hardships under our funding guidelines UNLESS you can verify that the situation is the direct result of one of our qualifying hardship categories. If homeless, how long?*Please select any of the following you are seeking assistance with:*You may upload copies of these bills/statements under "Supporting Documents" below. If you do not have them available for upload at this time, we will contact you with instructions on how to submit them separate from your application. Emergency/ short-term housing Funeral/ burial expenses Past due rent/mortgage Past due utility bills Medical bills Rental/Utility Deposit(s) Other Social Security Number Last 4 digits*If you are seeking assistance with a past due utility bill or a medical bill, please provide the last four digits of the social security number of the account holder Please note: Grants are NOT awarded to help with: Paying off credit cards, pay-day loans, or title loans Fees or Tuition for school Car repairs Making car payments Down payments on a vehicle Fuel Cable, internet, cell phone and other subscriptionsUtility companies have, for the time being, suspended disconnections. Most evictions and foreclosures have also been put on hold. As a result, grants for assistance with past due utilities, rent, and mortgage have been temporarily restricted to allow us to focus our response on situations where individuals’ welfare and safety are in immediate jeopardy. We understand there may be other mitigating circumstances and will continue to review every application on a case-by-case basis. Amount Requested*USD ($)Entity Payable To*The Fund pays assistance directly to creditor, not to individual applicants. For example, if you are seeking assistance with funeral expenses, the Fund would pay directly to the funeral home. Please describe the emergency hardship situation*What incident(s) contributed directly, and indirectly, to the applicant's financial hardship?Please describe in detail the Applicant's need*Please describe in detail what the funds will be used for*Did you have to take unpaid time off or work, or a reduction of hours, as a direct result of this hardship?*YesNoPlease explain.For example: If you took time off, how many days? Have you returned to work? If your had to reduce your hours, by how much and when do you expect to be able to resume your normal work load?Supporting DocumentsFire: Please let us know if you have done any of the following (mark all that apply):*You may submit copies/photos in the "File Upload" sectionbelow or email separately. Filed an insurance claim Spoken to the American Red Cross Received a fire report Taken photos of the damage None at this time Homeless: Please let us know if you have done any of the following (mark all that apply):* Found a new place but need help with deposits to move in Secured temporary shelter with family/friends Been sleeping in vehicle Contacted homeless shelters Applied for subsidized housing None at this time Secuirty Deposit and Rent Please submit something in writing from the landlord detailing what money is due to move-in and to whom to make payment. If you will be renting from an independent landlord, we will also need a copy of his/her photo ID. Utility Deposit If you need assistance with deposit to get electricity and/or water turned on in your new residence, please submit something in writing from the utility company detailing the charges.Emergency/ Short-term Housing Please submit something from the motel/hotel in writing stating weekly rate plus taxes and fees and contact information for the general manager, including email address and fax number. If your request is approved, we will work directly with the property to arrange for "third party" payment for your room. Natural Disaster: Please let us know if you have done any of the following (mark all that apply):*You may submit copies of these in the "File Upload" section below or email separately. Filed an insurance claim Spoken to the American Red Cross Taken photos of the damage None at this time Death: Please let us know if you have of the following (mark all that apply):*You may submit copies of these in the "File Upload" section below or email separately. Statement/Invoice from funeral home Obituary for the deceased Death certificate None of these at this time Illness: Please let us know if you have any of the following (mark all that apply):*You may submit copies of these in the "File Upload" section below or email separately. Doctor's note with excuse from work and/or school Hospital/ER discharge papers Medical bills None of these at this time Accident/ Crime: Please let us know if you have any of the following (mark all that apply):*You may submit copies of these in the "File Upload" section below or email separately. Police report Photos of injury/ damage Other documentation verifying accident/crime None of these at this time Monthly BudgetOnce your current hardship is resolved, what will your monthly budget look like? Using one of these templates, please complete and submit your monthly budget. Monthly Budget Worksheet (PDF) Monthly Budget Spreadsheet (Excel) To submit your budget you may: Upload a copy with your application using the "File Upload" section below; or Email it to us separately Every applicant must submit: Driver's license or other government issued photo ID Supporting documentation verifying hardship, requested assistance, and payable entities Copies of the bills you are seeking assistance to pay These images/files may be uploaded below under the "File Upload" section. If you can not upload them at this time, we will contact you via email or text with instructions on how to submit them separate from this application.File Upload Drop files here or Accepted file types: jpg, png, pdf, doc. Section III: Other Assistance(Must be Completed)Have you (the Applicant) requested any other support or assistance for this emergency situation?*(examples include other charitable or religious organizations, insurance, government aid programs or other federal, state or local assistance)YesNoIf not, please explain why*If yes, from whom?*If you requested other support or assistance, was it granted?*YesNoNot sure/ Haven't heardIf so, please specify total amounts*US $If any request was denied, please give reason for denial*Section IV: Prior Fund Assistance(Must be Completed)Have you, the Applicant, applied for a grant from Jack’s Family Fund prior to this application?*YesNoWhen was your request made?*Was it granted?*YesNo Section V: Applicant Certification(Must be Completed)I certify that to my knowledge I am in compliance with all laws, statutes and regulations restricting U.S. persons from dealing with any individuals, entities or groups who are subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers. I consent to the processing of my personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Jack’s Family Fund. I further consent to the transfer of the contents of this Application to the Fund located in Birmingham, Alabama, USA, the Jack’s Family Fund Administrator, the Jack’s Family Fund Board of Directors or Allocation Committee Members.I further certify to the Fund that the information contained in this Application is true and correct. By accepting a gift from the Fund, I agree to provide copies of the following materials if requested by the Foundation: receipts demonstrating the emergency hardship, my expenditure, and documentation illustrating my relationship to the Applicant, if I am submitting this application on behalf of someone else.Application Completed By*First and Last Name of person completing the application.Signature*Date* MM DD YYYY If you have any questions, please contact us.