2. 
4. Submit an Application for Assistance on behalf of an Employee / Retiree

   The Athens-Clarke County Charity Drive Committee (the "Committee") reviews applications for request and approves them provided they meet the following definition of emergency: "A severe financial hardship resulting from a sudden and unexpected illness or accident experienced by the employee/retiree or his/her dependent; and/or the loss of an employee/retiree's primary residence due to casualty." The Committee does not generally approve applications for requests to pay bills for which payment arrangements can be made with the creditor, lender, or service provider. Certain situations may warrant further inquiries from the Committee to the employee needing assistance into the details of the emergency hardship in order to approve or decline this request.

   The amount of assistance, which may be granted to a recipient, varies depending on the emergency. There is a maximum limit per incident of $1,000 for individuals who currently contribute at least $50/year ($2 per pay period for biweekly employees) to the Employee Emergency Assistance Fund and a maximum of $350 to all other individuals. Individuals eligible for maximum assistance may receive $2,000 in a 12-month period, while all other individuals may receive up to $700 in a 12-month period. An employee is not eligible to receive assistance within the first 6 months of employment with Athens-Clarke County.

   If the committee finds that any claims regarding this request are intentionally false or that funds received by the applicant were not used for the intended emergency relief, the committee reserves the right to refuse future applications from the applicant.

   This description is intended to provide information only. It is not intended, and should not be taken, as a statement of legal rights and responsibilities. The description of services provided by the Committee Is subject to change or termination at any time by action of the Committee members.

6. Name and Telephone Number of the Person Submitting the Request on Behalf of the Employee / Retiree*
8. Have you spoken to the employee/retire regarding this request on their behalf?*

   1. Yes
   2. No
9. If no, please explain why.
11. Employee / Retiree First Name*
12. Employee / Retiree Last Name*
14. Address
16. City
17. State
18. Zip
20. Phone Number*
21. Alternate Phone Number
23. E-mail
25. Employee / Retiree Department*
26. Date of Hire*
28. Supervisor
30. 1) Is this request in response to a catastrophic event (terminal diagnosis, house fire) or natural disaster?*

    1. Yes
    2. No
32. 2) Is this request in response to a medical issue?*

    1. Yes
    2. No
34. 3) Is any part of the medical expense covered by insurance?*

    1. Yes
    2. No
    3. Unknown
36. 4) What amount of this expense the employee's / retiree's responsibility (NOT covered by insurance)?
38. 5) Has the employee / retiree exhausted all other available resources (checking/savings, HSA/FSA, cash on hand, investments, family, child support, etc.) to offset any part of this expense?*

    1. Yes
    2. No - Explain below
    3. Unknown
40. Explanation field for Question 5
42. 6) Has the employee / retiree attempted to make payment arrangements for this expense?

    1. Yes
    2. No
    3. Unknown
44. 7) Describe the emergency hardship. Include as much detail as possible, including the circumstances that led up to the emergency and how it has created a financial hardship for the employee / retiree.*
46. 8) If the Committee does not approve the request for assistance, how will this affect the employee / retiree? What, if any, other options are available to them?*
48. NOTICE

    I hereby swear or affirm that the information provided in this application, including any attachments, is true and correct to the best of my knowledge. I understand that I am required to advise the employee/retiree who I am requesting assistance for, when at all possible, of my intention to submit an application for assistance on his/her behalf. 

    I have provided an explanation of the emergency hardship with all relevant details, which may include attachments. I understand that the Committee may ask the employee/retiree for further information concerning the emergency hardship described in this application in order to assess this request. I understand that this information will be kept confidential by the Committee unless the information must be disclosed by law. I also understand that the Committee may require financial counseling prior to considering this application if the employee/retiree has submitted a request for assistance 3 or more times within the last 24 months. 

    I understand that if the Committee does not approve this application for assistance that I or the employee/retiree will be permitted one opportunity to make an appeal to the Committee and to submit any additional documentation that may be useful for Committee reconsideration. 

    I understand that I DO NOT HAVE A LEGAL RIGHT to request a copy of all information provided to the Committee in processing this application, as it contains protected, confidential information of the individual and/or family. 

50. Signed*

    Type your complete legal name here

51. Date*
    Date
53. Documentation

    Please provide as much supporting documentation as you can. Examples include:

    • Invoices for repairs, medical supplies, or other expenses related to the emergency situation
    • Water and/or power disconnect notices
    • Foreclosure or eviction paperwork
    • Deductible printout from your insurance carrier
    • Estimates for needed medical procedures, home repairs, etc.
    • Police report
    • Pictures
    • Anything else that helps detail the situation and/or supports the request
55. Please upload any documents as a single file.
57. Have a question? Contact your department's coordinator.
    Employee Assistance Department Coordinators
59. COMMITTEE USE ONLY
    • Does the applicant or recipient contribute at least $50/year to the Emergency Assistance Fund?

           Yes          No

    • Has the applicant or recipient been previously assisted?

            Yes          No

             If yes, when?

    
    

    
    

    • Is the application fully completed and signed by the applicant or proxy?

           Yes          No

    • Was documentation provided by the applicant or proxy?

            Yes          No

    • Have you spoken to the applicant, proxy, and/or supervisor?

            Yes          No

             If no, why?

    
    

    
    

    • Have you verified the information given (utility bills, evictions, payroll/disability, etc.)?

            Yes          No

            If no, why?

    
    

    
    

    • Reviewed by Committee Member:
    • Comments:

    
    

    
    

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61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

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