Hardship Application - Flagger Force

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FLAGGER FORCE FOUNDATION

To our valued Flagger Force Employee,

Thank you for your interest in applying for a grant through the Flagger Force Foundation Employee Hardship Grant Program. We recognize that difficult and unexpected circumstances arise, creating hardships for our employees. Asking for assistance is a humbling challenge, and we commend you for reaching out for help. Please also understand that the Flagger Force Foundation Employee Hardship Grant Program Committee is tasked with the very difficult process of deciding how to allocate their funds based on the greatest need among applicants. We regret that we may not be able to assist every applicant in full or even partial financial aid. In most cases, the Committee will try to provide recommendations of other means of assistance that can be applied for via government/social/community services if we are not able to meet the requested need.

Qualified Incidents: Qualified incidents are unexpected circumstances that arise outside of the employee’s control which causes an economic, legal or non-financial hardship for the employee’s family. A qualified incident is typically a one-time event that occurs unexpectedly and either causes the applicant to spend his/her rent and/or utility money on unexpected bills, causes an unexpected legal concern, or causes an unexpected non-financial need. The reported cause must have occurred within 90 days of the application date. Circumstances that may qualify for a grant fall into these categories:

Personal tragedy
Death
Medical emergency
Natural disaster
Catastrophic/extreme circumstances

Please read through this application carefully—there are many components of the application including financial documentation and we must receive all relevant paperwork completed in full for any application to be evaluated. Rest assured that all details are confidential, and that the application will be made anonymous (all identifying con- tact information will be removed from documents) before being reviewed by the decision-making committee, made up of fellow Flagger Force employees. The committee will review the application, including the nature of the incident, financial details, the employee’s current financial status, and other supporting documentation. The decision will be made within two weeks of receiving the fully completed application.

Additional information may be requested in order to approve the application. Failure to respond within 30 days of request will result in the application being closed.

If you should have any questions about the application process, please contact the Hardship Grant Administrator at the email address at the bottom of this page.

Regardless of the outcome, we are very sorry for your situation, and we wish you the best in facing and resolving your hardship.

Sincerely,

The Flagger Force Foundation Employee Hardship Grant Committee

HardshipGrant@FlaggerForce.com

Flagger Force Employee Hardship Grant Application

Has a recent unexpected life event caused you a financial hardship? The Flagger Force Employee Hardship Grant may be able to help. Complete the form below to apply for assistance. Please email HardshipGrant@FlaggerForce.com for more information or with any questions.

Contact Information

Name *

Employee ID *

Date *

Home Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Position held at Flagger Force *

Eligibility Requirements

I am an employee of Traffic Control Services, LLC, or TCS Management Inc, and have been employed for at least 6 months * YesNo

This hardship involves myself or my immediate family * YesNo

Please provide a headcount at your residence, including yourself: Adults (18+), and Children *

Adults (18+)

Children (10-17)

Children (5-9)

Children 4 and under

How many of these dependents do you claim on your federal taxes?

This hardship is an unexpected, unusual, and/or extraordinary event * YesNo

I have applied for assistance from the Employee Hardship Grant Program in the past * YesNo

(If Yes) when

(If Yes) What was the outcome

Please Provide a Brief Description of the current event that caused this hardship *

Event Date That Caused the Current Hardship *

List below all of the efforts you have taken to resolve this hardship, including other sources of financial or social aid *

Please describe below how the incident prevents you from meeting your financial obligations *

Financial Details

Please list the bills that you would like the Employee Hardship Grant to consider paying on your behalf. These bills must have been caused by the incident described in the application. Please be sure that the total amount of these bills is equal to the total dollar amount you are requesting on the application. If you are requesting goods or services, please document the specific needs and expected costs below.

Company Owed *

Address *

Essential Need Provided *

Account Number

Amount Owed ($) *

Name On the Account *

Company Owed

Address

Essential Need Provided

Account Number

Amount Owed ($)

Name On the Account

Company Owed

Address

Essential Need Provided

Account Number

Amount Owed ($)

Name On the Account

Total Need Requested*

Cash (Assets):

Cash on hand or checking: *

Savings Account Balance*

Other Accessible Cash *

Total*

Your MONTHLY Household Income:

Employee's Monthly Gross Wages: *

Spouse's Monthly Gross Wages

Child Support Rec'd:

Disability Insurance:

Social Security Income / Pension:

Other Income:

Total:*

Your MONTHLY Living Expenses:

Rent/Mortgage: *

Utilities: * (Phone, Gas, Electric, TV)

Food: *

Child Support Owed:

Medicine/Medical Costs:

Car Loans:

Gas/Incidentals/Other:*

Total:*

Upload Documents

REQUIRED DOCUMENTS • Copies of current bills or invoices listed below • A letter or invoice from landlord with amount owed, or mortgage payment coupon • A gift registry from a store like Target or Wal-Mart if you are seeking help to replace essential household items not covered by insurance • Other documents to substantiate current amounts owed

*Upload One Document Per Line

By submitting this application, I certify that the above information is correct and request that the Flagger Force Foundation reviews this application. I authorize FFF to obtain and/or verify all information necessary to process this application. Additionally, I understand that no employee is entitled to receive a grant, either by their employment, their history of contributions to the Foundation or because of any precedent inferred from a previously approved grant. I understand grants will not be made before an employee had demonstrated an immediate need.

I have read, understand and agree to the terms and conditions.