| Section I: Applicant Information | (Must be Completed) |
|---|---|
| Applicant's Name | Kiera Campbell |
| Email hidden; Javascript is required. | |
| Preferred Phone Number | (205) 396-4084 |
| Phone Type | Cell Phone |
| Home Address | 216 Olympia Villiage Dr Birmingham, Alabama 35209 United States Map It |
| Do you currently work for JFR or SFM? | Yes |
| If yes, what is the store number? | 210 |
| Employment Status | Full-time |
| Employer | Jack's Family Restuarant |
| Employer Address | 2259 Mt. Olive Brookside Rd Mt.olive, Alabama 35117 United States Map It |
| Average number of hours per week | 50 |
| Salary/Hourly Wage | $13.18 |
| Section II: Beneficiary Information | (Must be Completed) |
| What is your relationship to the beneficiary? | I am the beneficiary |
| Beneficiary's Full Name | Kiera Campbell |
| Beneficiary's Address | 216 Olympia Village Birmingham, Alabama 35209 United States Map It |
| Preferred Phone Number | (205) 396-4084 |
| Phone Type | Cell Phone |
| Beneficiary's Employer | Jack's Family Restuarant |
| Section III: Request for Financial Assistance | (Must be Completed) |
| Hardship Category |
|
| Amount Requested | $3,500.00 |
| Entity Payable To | Kiera Campbell |
| Please describe the Beneficiary's emergency hardship situation | During the fire on 2-23-19 my family, and I lost furniture, clothing, and the inconvenience of a home to stay. We are seeking assistance from JFR to help us at least replace the many things that we lost. Although the times may be hard, we are asking for anything that may be able to help us start back over with this. If the amount requested is not something they may be able to be given, we are asking for as much that can. |
| Please describe in detail the Beneficiary’s need | Clothing and furniture |
| Please describe in detail what the funds will be used for | The funds will be used to help replace furniture and clothing |
| Section IV: Other Assistance | (Must be Completed) |
| Have you or the Beneficiary requested any other support or assistance for this emergency situation? | No |
| If not, please explain why | Currently seeking support from family, and friends |
| Section V: Prior Fund Assistance | (Must be Completed) |
| Have you or the Beneficiary applied for a grant from Jack’s Family Fund prior to this application? | No |
| Section VI: Applicant Certification | (Must be Completed) |
| HTML Block | 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 Foundation 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 Foundation that the information contained in this Application is true and correct. Additionally, if I am submitting this application on behalf a Beneficiary, I certify to the Foundation that the Beneficiary is my Immediate Family Member. 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 Beneficiary, if I am submitting this application on behalf of an Immediate Family Member. |
| Applicant Signature | Kiera Campbell |
| Date | 02/26/2019 |
| Custom Content | This is custom content field on Single Entry view. Could we use this to make the entry view more reader friendly for board? |
| Section VII: Beneficiary Certification | (Must be Completed) |
| HTML Block | I certify to the Foundation that the information contained in this application is true and correct. 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 Foundation located in Birmingham, Alabama, USA, the Jack’s Family Fund Administrator, the Jack’s Family Fund Board of Directors or Allocation Committee Members. |
| Beneficiary Signature | Kiera Campbell |
| Date | 02/26/2019 |
| Signature | |
| Date | 02/26/2019 |