Employee Financial Assistance Application

Please provide supporting documentation to your HR Director. (Ex. Accident report, insurance claim report, home eviction notice, past-due bills)

By submitting this application, the applicant agrees to the following:

In order to confirm the Applicant meets the financial needs requirements of the program, the Applicant will provide the Foundation with Applicant’s most recently filed Federal income tax return or Forms W-2 and 1099 for Applicant and Applicant’s spouse. Failure to provide substantiating information shall disqualify the Applicant from receiving an award under the program.

The Foundation may request employment records from Maxwell Group to confirm satisfaction of the requirements for receipt of an award under this program.

The Foundation may utilize Applicant’s banking records on file with Maxwell Group for the sole purpose of making ACH transfers of any amounts awarded under the program. If Applicant prefers to utilize different banking information, Applicant must submit preferred ACH information to the Foundation along with this application.

All records provided to the Foundation in connection with this application will be held confidentially and will not be disclosed to third parties by the Foundation except as provided by law.