APPLICATION FOR HOPE FUND ASSISTANCE - Scripps Health

APPLICATION FOR HOPE FUND ASSISTANCE

PROGRAM GUIDELINES AND CRITERIA

PROGRAM OBJECTIVE: HOPE stands for "Helping Our Peers in Emergency". It is a crisis fund supported by Scripps' employees for Scripps' employees. It's our way of reaching out to help someone in need.

ELIGIBILTY CRITERIA:

(Must meet all criteria to qualify)

Full-time, Part-time, or Casual employee Employee must have worked 1,000 hours or more in the previous year Employee has been employed with Scripps no less than 180 days (approx. 6 months) Employee has not received a formal corrective action or written warning within the last six months No employee will be eligible for aid more than two times in a 24-month period during his or her employment

with Scripps Health PTO hardship hours, if available, will be accessed prior to HOPE Fund approval

QUALIFYING EVENTS: (Per the IRS Safe Harbor guidelines)

Funeral expenses of parents, spouse, children or dependents Expenses for medical care previously incurred by the employee, the employee's spouse or any dependents of

the employee or necessary for these persons to obtain medical care Costs directly related to the purchase of a principal residence for the employee (excluding mortgage

payments) Payments necessary to prevent the eviction of the employee from the employee's principal residence or

foreclosure on the mortgage on the residence Certain expenses relating to the repair of damage to the employee's principal residence due to catastrophic

casualty loss Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of

postsecondary education for the employee, or the employee's spouse, children, or dependents

AWARD AMOUNTS: Individual award amounts will vary, but are not to exceed $2,000 $500 may be awarded at the site level, but requires approval All requests, regardless of amount, require supporting hardship documentation.

SELECTION PROCESS: Selection is based on the following (but not exclusive to) o Completion of the application o Meeting all eligibility requirements o Hardship falls within IRS Safe Harbor guidelines o Employee provides documentation of proof of hardship o Employee provides details of hardship as well as financial plan for the future

APPLICATION PROCESS: Complete the HOPE Fund application in full, include all supporting documentation, and submit to your site Human Resources office. The site HOPE committee will review the request and determine eligibility and request more information, if necessary. Based on the review and findings of the committee, they will either approve or disapprove the request. o If the site committee approves: The request is submitted to payroll for the initial award of $500. The request is then forwarded to the system-wide HOPE Fund committee for further review of the remaining amount requested. o If the site committee denies: A site Human Resources representative will contact the employee with an explanation for the denial.

If you have questions or need more information, contact your site Human Resources Department

REQUEST FOR ASSISTANCE APPLICATION

APPLICANT NUMBER: ____________________ (CHAIRPERSON TO ASSIGN)

PLEASE PRINT OR TYPE APPLICATION.

So that we can process your request as quickly as possible, please complete everything on this form. This information will be given to a member of the HOPE Fund team. You will be contacted soon for more information. The information you provide will be kept confidential. It will only be reviewed by those necessary to your application process.

NAME: ______________________________________________________________

Last

First

Middle Int.

EMPLOYEE ID #: ___________ SOCIAL SECURITY #: _____________________

HOME ADDRESS: _____________________________________________________

CITY: ___________________________ STATE: ____________ ZIP: ____________

HOME PHONE: _______________________CELL PHONE: ____________________

WORK LOCATION: ______________________DEPT: ________________________

DATE OF HIRE: __________________ WORK PHONE: _____________________

JOB TITLE: ___________________________________________________________

NUMBER OF YEARS OF SERVICE AT SCRIPPS HEALTH: ____________________

CURRENT STATUS:

FULL-TIME

PART-TIME

CASUAL

TOTAL AMOUNT REQUESTED: $__________ DATE NEEDED: __________________

If your request is granted, do you wish to:

Have your check mailed (address) _____________________________________

Pick up check

I authorize Human Resources to verify the information provided on this form. I also authorize Human Resources to gather any additional information needed by the committee to process this request.

I hereby acknowledge that the attached information is correct.

SIGNATURE: _______________________________________ Date: __________

Request For Assistance Application ? Rev. 1/2010

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REQUEST FOR ASSISTANCE APPLICATION

APPLICANT NUMBER: ____________________ (CHAIRPERSON TO ASSIGN)

PLEASE PRINT OR TYPE APPLICATION.

The following information will be reviewed by the HOPE Fund Site and/or System Committee to determine financial eligibility. The information is strictly confidential. Therefore, DO NOT list your name on pages 3 and 4. Your file will be assigned an application number for accounting purposes only.

Have you received HOPE Fund or Employee Emergency Trust Fund grants previously?

YES

NO

If yes, amount: $____________________

Date received: _________________________

Reason: _____________________________________________________________________

Describe the nature of your hardship. Explain what led you to your current financial situation. (Please include as much information as possible to assist the HOPE Fund committee. Continue on an additional piece of paper if needed.)

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

If your request for assistance is approved, what are your plans going forward to reconcile the hardship and prepare for the future?

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

Please attach copies of priority bills you wish to be considered for payment.

Please deliver completed application to Human Resources.

Request For Assistance Application ? Rev. 1/2010

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REQUEST FOR ASSISTANCE APPLICATION

APPLICANT NUMBER: ____________________ (CHAIRPERSON TO ASSIGN)

Please fill out as completely as possible. If supporting documents are attached for those areas marked with an asterisk*, your application may be processed more quickly.

DEPENDANTS (DO NOT LIST NAMES)

Relationship

Age

Relationship

Age

MONTHLY INCOME * Net (take home pay, provide previous 2 paystubs) * Workers' Comp * State / Long Term Disability * Unemployment Insurance * Spouses Income (Include unemployment / disability / previous 2 paystubs) Other Sources of Income * Dependant's Income * Child Support * Alimony * Social Security * Rental Property * Stocks / Bonds / Dividends Assets Checking Acct(s) #___________________________ Savings Acct(s) #____________________________ Credit Union #_______________________________ Miscellaneous ______________________________

MONTHLY EXPENDITURES Rent / Mortgage Child Care Automobile Payments Food Gas / Electric / Phone Water / Trash / Sewer Gasoline (Auto) Insurance Policies Life (Premium) Home Owners / Auto Medical / Dental Other Expenditures Loan Payments Charge Cards Medical / Dental Bills Miscellaneous

AMOUNT $ $ $ $ $

$ $ $ $ $ $

$ $ $ $

AMOUNT $ $ $ $ $ $ $

$ $ $

$ $ $ $

Request For Assistance Application ? Rev. 1/2010

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REQUEST FOR ASSISTANCE APPLICATION

APPLICANT NUMBER: ____________________ (CHAIRPERSON TO ASSIGN)

THIS SECTION TO BE COMPLETED BY THE SITE COMMITTEE:

DATE APPLICATION RECEIVED: ______________________________________________

DATE TO SITE HOPE REVIEW COMMITTEE: ____________________________________

DATE TO SYSTEM HOPE REVIEW COMMITTEE: _________________________________

RECOMMENDED SIGNED:

DENIED SIGNED:

INITIAL AMOUNT RECOMMENDED: $______________________

ADDITIONAL FUNDS RECOMMENDED? YES

NO

COMMENTS: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________

CONFIDENTIAL (HUMAN RESOURCES ONLY):

CHECK WRITTEN TO:

CHECK NO:

AMOUNT:

$

NOTIFICATION GTO EMPLOYEE DATE:

DATE: PHONE:

EMPLOYEE WISHES CHECK TO BE:

Mailed: (Address) _____________________________________________________

Picked Up: (Date and Time, if applicable) ___________________________________

Request For Assistance Application ? Rev. 1/2010

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