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Employee Hardship Fund Grant Application

Effective January 1, 2012

Employee Hardship Fund Grant Application Instructions:

In order for your application to be processed, all sections on this form must be completed accurately and approved by Human Resources.
The application steps are as followed: 1. Complete all of the fields in Section I PLEASE PRINT CLEARLY. 2. In Section II, choose the reason for your hardship by checking the appropriate box. 3. Attach your supporting documentation for your hardship reason; if supporting documentation is not supplied, your application will be denied. 4. For Section III, all six (6) boxes must be checked. By checking each box, you are acknowledging that all of the requirements have been met. Failure to check each of the six (6) boxes in Section III will lead to the application being denied. 5. You must sign and date the application. 6. Provide the completed application to Human Resources. Human Resources will review the application and the supporting documentation. 7. Obtain approval from your Human Resources Vice President by having him/her print his/her name, sign the application, and date it. 8. Human Resources will forward the completed application to Payroll for final verification and processing. 9. Final review process: If it is determined that one or more of the requirements have not been met, you will be notified via Human Resources. If the application requirements have been satisfied, your hardship grant will be paid via manual check.

EHFGA_2012.0522

Employee Hardship Fund Grant Application


Effective January 1, 2012
SECTION I: Please complete the fields below Employee ID: Email Address:

Employee Name: Home/Cell Phone: Home Mailing Address:

Amount of Request:
(maximum = $1,000)

SECTION II:

Please indicate your reason for the hardship by checking the appropriate box

Hardship Reason (attach documentation to support your request): To prevent eviction from my primary residence Unreimbursed medical expenses for which I am personally responsible To prevent the loss of core utilities (water, gas, or electric) at my primary residence Funeral expenses for which I am personally responsible Repairs to my primary residence due to a disaster or fire I am ineligible for, or have exhausted, paid leave relating to: o FMLA relating to the care of my ill spouse, child, or parent o Death of an immediate family member SECTION III: All requirements must be met to be considered for the program. Please mark each box below to indicate that each requirement has been met

Certification: I certify that I have met the following requirements to submit this application: I am a regular Full-time, Flex Full-time, Job Share, regular Part-time or Limited Part-time staff member and have completed my orientation period (not Temporary or Casual). I have not received an Employee Hardship Fund Grant within the last two years. I have had an initial counseling session with UPMC LifeSolutions before making this application and have signed the EAP Consent to Obtain/Release Information form. I hereby certify that I have no other sources of funds available to meet the financial need above, such as a grant from another source, commercial loan, insurance, or through the sale of other assets. I have attached the appropriate documentation relating to my financial need and certify that it meets at least one of the criteria checked above. I understand that funds must be available in the UPMC Employee Hardship Fund to award any grant under this program. SECTION IV: Please sign and submit for review
By my signature, I am also authorizing UPMC and its agents to contact and verify the source of my request for the financial hardship grant.

HR Vice President Name

Employee Signature

Date

HR Vice President Signature

Date

Payroll Representative Approval


EHFGA_2012.0522

Date

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