Grant Application

Are you completing this application on behalf of someone else?*
- Yes
- No
Your Name*
First Last
Your Email*
Your Preferred Phone*
Preferred Phone Type*
Do you currently work for JFR or SFM?*
- Yes
- No
If 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?*
If other, please explain.*
Section I: Applicant Information
The applicant is the individual who is experiencing the hardship/ in need of assistance.
Applicant's Name*
First Last
Applicant's Email*
Applicant's Preferred Phone Number*
Phone Type*
Home Address*
Street Address City State Postal Code
Does the applicant currently work for JFR or SFM?*
- Yes
- No
If 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.*
- Yes
Employment Status*
Employer*
Employer Address*
Street Address City 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?*
Where 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?
- Yes
- No
If 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"

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)
- Yes
- No
If not, please explain why*
If yes, from whom?*
If you requested other support or assistance, was it granted?*
- Yes
- No
- Not sure/ Haven't heard
If 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?*
- Yes
- No
When was your request made?*
Was it granted?*
- Yes
- No

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

Step 1 of 4

Section I: Applicant Information

Section II: Request for Financial Assistance

Supporting Documents

Monthly Budget

Every applicant must submit:

Section III: Other Assistance

Section IV: Prior Fund Assistance

Section V: Applicant Certification