The Homer Fund Direct Grant Application

Transcription

1 Overview Paper applications accepted from April 2 29, 2015 ONLY The Homer Fund Direct Grant Application The Homer Fund helps associates who cannot afford housing, utilities, food, clothing, funeral expenses and uninsured home repairs because of a natural disaster, illness, injury, recent unemployment, or death. The Homer Fund may also assist with relocation if their home is uninhabitable or condemned, or if forced to relocate due to unanticipated sale or foreclosure of leased property. All current associates of The Home Depot are eligible to apply for grants from The Homer Fund; however, the qualifying event causing the financial need must occur while employed with the company. The maximum grant amount of each Direct Grant is $10,000, but grant amount will be based on actual need. An associate can receive only one Direct Grant for the same qualifying circumstance within a 12-month period, regardless of the amount granted. An associate can receive both a Direct Grant and a Matching Grant for the same qualifying circumstance. Direct Grant Process Associates should work with their manager to complete the following Direct Grant application process: 1. Determine the associate s eligibility for Direct Grant assistance by completing the quick test below. 2. If eligible, complete Page 2 of this application and the corresponding page for the associate s qualifying circumstance. 3. Associate signs the application as verification that all information is true and correct, and as authorization for the Fund to verify all information and/or to obtain additional information. 4. Obtain two sponsor signatures (refer to sponsor signature list on Basic Information page). 5. Gather all necessary supporting documents and fax the completed application to the Fund at (770) Decisions are usually made within 3 business days (excluding weekends and holidays), after the Fund has received a completed application containing all necessary information and supporting documents. 7. If an application is approved, a check made payable to either the associate or another appropriate party (mortgage or utility company, etc.) is sent via overnight mail to the manager for disbursement. Eligibility Quick Test (COMPLETION REQUIRED) To determine if the associate is eligible for Direct Grant assistance, answer Yes or No to the following questions: 1. Is the impacted person one of the following? Associate Associate s spouse Associate s dependent child(ren) Other qualified dependent (defined as legal dependent eligible for company-sponsored benefits, or is eligible to claim on tax return and has resided with associate for 6+ months) If the impacted person is not one of the persons listed above, your request surpasses The Homer Fund criteria. Please review the guidelines for a Matching Grant. 2. Is this a request for medical bills, insurance premiums or car payments? Yes No If this is a request for the above, your request surpasses The Homer Fund criteria. Please review the guidelines for a Matching Grant. 3. Is the associate unable to pay for one or all of the expenses listed below? Housing (must have received a past due notice or needs help to pay security deposit for rental) Utilities (must have received a past due notice for electricity, gas, water, sanitation; needs help to pay deposit to establish essential utilities) Past due homeowners association fees or property taxes Funeral expenses Food Clothing If the basic need is not identified above, your request surpasses The Homer Fund criteria. Please review the guidelines for a Matching Grant. 4. Is the associate s need for or inability to pay for these expenses (from Question 3) a direct result of one of the following circumstances? Natural Disaster Recent unemployment of spouse or associate s second Fire job (loss of Home Depot employment excluded) Illness or injury Homelessness (without physical shelter) Death of associate or immediate family member (spouse, minor child or dependant of associate) Uninhabitable/condemned housing due to mold, rodent/insect infestation or code violation Unanticipated sale or foreclosure of leased property If the circumstance is not identified above, your request surpasses The Homer Fund criteria. Please review the guidelines for a Matching Grant

2 BASIC INFORMATION (Must be completed for all Direct Grant applications) Paper applications accepted from April 2 29, 2015 ONLY SPONSORING STORE INFORMATION Home Depot #: At Home Services # DC/IDC # HD Direct # SSC (city ) YOW Other: Store Mailing Address: Phone #: ( ) - Ext. Alt. Phone #: ( ) - ASSOCIATE S INFORMATION (items in bold must be completed) Home Depot Division: Northern Southern Western Home Depot Region: Home Depot District #: Legal Name: Associate ID Number: Street Address: City: State: Zip: Phone Number: ( ) - Address (if available): Alt. Number: ( ) - Associate s Store Position/Title: / / If awarded a grant, I give The Homer Fund permission Associate s Signature Date to use my story (check if you agree). **My signature serves as verification that all information provided on this application is true and correct, and authorizes The Homer Fund to verify all information and/or to obtain additional information as needed to complete my request for assistance. REASON FOR APPLICATION Please mark reason for application and complete appropriate page: Natural Disaster/Fire i.e., hurricane, flood, earthquake, tornado, wind/ice storm, wild fires, etc. (complete pages 3, 9 & 10) Illness/Injury (complete pages 4 & 9) Uninhabitable or Condemed Housing (complete pages 6, 9 & 10) Death (complete pages 5 & 9) Sale or Foreclosure of leased property (complete pages 6, 9 & 10) Homelessness (complete pages 8, 9 and 10) Unemployment (complete pages 7 and 9) Uninsured Home Modification (complete pages 4 & 9) Brief description: SPONSOR INFORMATION All Direct Grant applications require two sponsor signatures. This confirms that the associate s circumstance meets the minimum qualifications for a Direct Grant and that the sponsors recommend grant assistance. Applications will not be processed without the proper signatures. I have completed the quick test from Page 1 and have determined this associate meets the minimum qualifications for Direct Grant assistance. I recommend that The Homer Fund provide a grant in the amount set forth below to the associate listed above. Date: / / Recommended amount: $ ($10,000 maximum) SPONSOR #1 SPONSOR #2 Signature Print Name and Title Please check the appropriate store sponsors: Human Resources Generalist District Human Resources Manager Store Manager District Manager Officer (President, Vice President) Signature Print Name and Title Please check the appropriate non-store sponsors: Human Resources Manager Department Manager Director Officer (President, Vice President)

3 NATURAL DISASTER/FIRE The Homer Fund helps associates who are unable to pay for housing, utilities, food and clothing because of a natural disaster or a fire that has damaged or destroyed his or her primary residence. Temporary housing (such as hotel until primary residence is rebuilt) Security deposit to move into new rental home/apartment Essential utility bills/deposits (electricity, natural gas, water, sanitation) Past due homeowners association fees and property taxes Uninsured/underinsured home repairs Homeowners insurance deductibles (up to $1,000) Clothing and food Down payment on new home Auto repairs or replacement Electronics Furniture Appliances Generators Non-essential utilities (cable, phone, cell Moving expenses/storage expenses Home repairs covered by insurance What type of natural disaster has affected the associate? Fire Tornado Flood Hurricane Earthquake Blizzard Mudslide Ice/Wind Storm Tsunami Yes No Does the associate have homeowners or renters insurance? If the associate has insurance, how much has the insurance company paid thus far? $ How did the associate use the funds issued? Is the insurance company paying for the associate s immediate needs? Is the insurance company reimbursing the associate for out-of-pocket expenses? Can the associate live in his or her primary residence? Is the associate seeking help with paying for home repairs? If so, attach copy of repair estimate. Is the associate seeking assistance to move into a new apartment/rental home? If so, a landlord statement (page 10) is required. Where is the associate currently living? With relatives With friends Hotel/motel What essentials does the associate need help with? Temp. housing New housing Replace clothing Food If an apartment/rental home, what is the apartment complex/landlord doing to assist the associate (refunded security deposit/rent, provided another apartment/rental home, discounted rent)? Document Checklist (The following documents are required when sending this application for review): Fire report/police report Landlord statement for new apartment/rental home stating all monies needed to move-in (security deposit, first month s rent, etc.) Essential utilities deposit statements (electricity, gas, water, sanitation) Any other documentation relevant to this request (insurance report, etc.)

4 ILLNESS OR INJURY The Homer Fund helps associates who are unable to pay for housing, utilities, food, clothing and uninsured home modifications because of an illness or injury suffered/sustained by the associate or an eligible dependent. Eligible dependent means the associate s spouse and minor children, and other dependants for whom the associate is 100% financially responsible (dependant eligible for coverage under the associate s benefits or ability to claim as a dependent on tax returns). Typically parents, grandparents, or other relatives are not considered dependants, unless the associate can show they are 100% financially responsible for that relative. Past due rent/mortgage Past due essential utilities (electricity, natural gas, water, sanitation) Food and clothing Rent/essential utility deposits - if moving into more affordable housing (electricity, natural gas, water, sanitation, homeowners association fees, property taxes only) Home modifications (wheelchair ramp, doorways, bathroom, lifts etc.) Necessary hotel accommodations (up to $100 per night) to accompany a hospitalized qualifying dependent Medical Bills Treatment costs (surgery, chemotherapy) Insurance premiums/co-pays Medication/Medical Equipment Non-essential utilities (cable, phone, cell Transportation (gas, repairs, airfare, moving expenses, etc.) Auto payments, credit cards, personal loans (including loans from family), child care Who is ill/injured? Associate Spouse Minor Child Other Dependent: What is the nature of the illness/injury? Yes No Is the affected person covered by medical insurance? Does the affected person have any medical bills that are not covered by insurance? If so, how much? $ Is/was the affected person on a Leave of Absence due to the illness or injury? If yes, what is/was the start date of the leave and expected return date? Start date / / Return or expected date / / PLEASE PROVIDE PHYSICIAN S STATEMENT CONFIRMING ONSET, DURATION, AND EXPECTED DATE OF RETURN If the associate is not the ill or injured party, does the affected person live with the associate? Is the ill/injured person covered by disability insurance? Is/was the affected person receiving disability benefits? If so, how much? $ /week Has the associate applied for disability? Is there a need for home modifications? Are there any past due basic utilities as defined above? Is the associate being evicted or foreclosed? (If mortgage, read and complete page 11) Document Checklist (The following documents are required when sending this application for review): Physician s statement/loa paperwork Past due notices for rent/mortgage/essential utilities Rent/essential utilities deposit statements (if moving into more affordable housing) Any other documentation relevant to this request (medical bills to support claim of high bills, etc.)

5 DEATH The Homer Fund helps associates who are unable to pay for housing, utilities and food because of the death of the associate or an eligible dependent. The Fund may be able to help if the loss of income or the payment of funeral expenses prevents an associate or eligible dependent from paying basic living expenses. The Homer Fund also assists with funeral expenses for associates or eligible dependents if the associate is unable to afford the funeral. Eligible dependent means the associate s spouse and minor children, or other dependants for whom the associate is 100% financially responsible (dependant eligible for coverage under the associate s benefits or ability to claim as a dependent on tax returns). Typically parents, grandparents or other relatives are not considered dependents; unless the associate can show they were 100% financially responsible for that relative prior to their death. Funeral expenses essential costs only Past due rent/mortgage Past due basic utilities(electricity, natural gas, water, sanitation) Rent/basic utilities deposits - if moving into more affordable housing Past due homeowners association fees or property taxes Food (where appropriate) Clothing (where appropriate) Newspaper notices, floral arrangements, acknowledgements, limousines, grave markers/headstones, and other nonessential burial expenses Medical bills Insurance premiums/co-pays Transportation (gas, repairs, airfare, moving expenses, etc.) Non-essential utilities (cable, phone, cell Who is the deceased? Associate Spouse Minor Child Other Dependent: What caused the death? Yes No Did the deceased have life insurance? If so, who is the beneficiary? Were funds used to cover funeral expenses? Did the deceased work outside of the home or have other income? Is the associate being evicted or foreclosed as a result of death? (If mortgage is past due, please read and complete page 11) Are there any unpaid funeral expenses? If so, how much? If expenses have been paid, who made the payment? PLEASE PROVIDE COPY OF FUNERAL EXPENSE STATEMENT WITH YOUR APPLICATION What is the name, address and phone number of the funeral home/cemetery requiring payment? Name of Funeral Home/Cemetery: Funeral Home/Cemetery Mailing Address: Phone Number of Funeral Home/Cemetery: ( ) - Document Checklist (The following documents are required when sending this application for review): Itemized funeral expenses bill/quote Past due notices for rent/mortgage/essential utilities Rent/essential utilities deposit statements (if moving into more affordable housing) Any other documentation relevant to this request (medical bills, etc.)

6 UNINHABITABLE/CONDEMNED HOUSING OR UNANTICIPATED SALE OR FORECLOSURE The Homer Fund helps associates with relocation if their home is uninhabitable or condemned, or if forced to relocate due to unanticipated sale or foreclosure of a property they rent from a private landlord. Housing (such as hotel until primary residence is rebuilt) Security deposit to move into new rental home/apartment Essential utility bills/deposits (electric, natural gas, water, sanitation) Past due homeowners association fees or property taxes only Clothing and food (where appropriate) Home repair/rebuilding costs/building supplies Down payment on new home Auto repairs or replacement Moving expenses/storage expenses Insurance deductibles Non-essential utilities (cable, phone, cell Furniture/Appliances/Generators Electronics Which situation applies to this associate? Unanticipated Sale/Foreclosure of leased property - attach related verification (i.e., notice to evacuate, foreclosure notice) Uninhabitable/condemned Housing (i.e., mold, rodent/insect infestation, code violation) Yes No Does the associate have renter s insurance? If so, has the insurance company paid the associate? If yes, how much? Can the associate live in primary residence? If so, what is the move-out date? / / Is the associate seeking assistance to move into a new apartment/rental home? If so, a landlord statement (page 10) is required. Where is the associate currently living? With relatives With friends Hotel/motel When did landlord notify associate of sale or foreclosure (provide notice of sale/foreclosure)? / / When did associate establish home was condemned or uninhabitable (provide inspection notice)? / / If an apartment/rental home was damaged or destroyed, what is the apartment complex/landlord doing to assist the associate (i.e., refunded security deposit/rent)? Document Checklist (The following documents are required when sending this application for review): Notice to vacate/foreclosure notice Notice of condemnation/other documentation showing home uninhabitable Landlord statement for new apartment/rental home stating all monies needed to move-in (security deposit, first month s rent, etc.) Essential utilities deposit statements (electricity, gas, water) Any other documentation relevant to this request (insurance report, etc.)

7 UNEMPLOYMENT The Homer Fund helps associates who are unable to pay for housing, utilities, food and clothing because of the recent unemployment of the associate s spouse or of the associate s secondary job. Unemployment must be involuntary (i.e., lay-off or company closure) and have taken place within the last six months. Past due rent/mortgage Past due essential utilities (electricity, natural gas, water, sanitation) Rent/essential utility deposits - if moving into more affordable housing (electricity, natural gas, water, sanitation, homeowners association fees, property taxes only) Food (where appropriate) Clothing (where appropriate) Medical Bills Auto payments, credit cards, personal loans (including loans from family), child care Non-essential utilities (cable, phone, cell Transportation (gas, repairs, airfare, moving expenses, etc.) Insurance premiums/co-pays Medication/Medical Equipment The person who lost their job is: Associate Spouse When did the job loss occur? / / What was the reason for the job loss? PLEASE PROVIDE SEPARATION NOTICE FROM EMPLOYER OR DOCUMENTATION FROM UNEMPLOYMENT OFFICE Yes No Was the affected person s job loss involuntary? (attach separation notice) Is their past due rent or mortgage? (attach statement from landlord or mortgage company) If mortgage is past due, please read and complete page 11. Are there any past due basic utilities as defined above? (attach current copies of past due bills) Has the affected person applied for unemployment? Is the affected person receiving unemployment insurance? If so, how much? $ /week Does the affected person remain unemployed? If no, when did they return to work? / / Document Checklist (The following documents are required when sending this application for review): Separation notice or documentation from unemployment office Past due notices for rent/mortgage/essential utilities Rent/essential utilities deposit statements (if moving into more affordable housing) Any other documentation relevant to this request

8 HOMELESSNESS The Homer Fund helps associates who are without physical shelter. The Fund will assist the associate with temporary housing, or help them to re-establish residence in a new place. Temporary housing (cover up to 2 months at an Down payment on new home extended stay hotel) Moving expenses/storage expenses Security deposit to move into new rental Furniture home/apartment (must be financially able to Appliances pay monthly rent) Electronics Essential utility bills/deposits (electricity, natural Non-essential utilities (cable, phone, cell gas, water, sanitation) Clothing and food (where appropriate) What caused associate to become homeless? How long has associate been homeless? Where is the associate living currently? With relatives With friends Hotel/motel Yes No Is the associate seeking assistance to move into a new apartment/rental home? If so, a landlord statement (page 10) is required. Is the associate seeking assistance to move into an extended stay hotel? If so, hotel manager must complete statement on page 10. What is the estimated length of hotel stay? days / weeks / months (circle one) Can the associate afford to pay monthly rent? (complete financial worksheet on page 9) Document Checklist (The following documents are required when sending this application for review): Landlord statement for new apartment/rental home stating all monies needed to move-in (security deposit, first month s rent, etc.) Landlord statement for hotel rate (daily/weekly rate, including taxes) Essential utilities deposit statements (electricity, gas, water, sanitation) Any other documentation relevant to this request (insurance report, etc.)

9 FINANCIAL WORKSHEET (Must be completed for all Direct Grant applications) Associate Name: Associate ID Number: Store #: The Homer Fund looks at all the bits and pieces of every situation in order to determine eligibility. Seeing an associate s financial picture helps us to better understand and appreciate the associate s circumstances. Before receiving a grant, an associate must show that he or she can afford the monthly rent going forward. Your MONTHLY Household Income: Associate s Monthly Gross (Pre-tax) Pay $ Spouse s Monthly Gross (Pre-tax) Pay $ Contributions From Other Adults In Household $ Child Support and Alimony Received $ Disability Insurance $ Social Security/Pension $ Income from TANF or SNAP $ Other Income $ Total $ Amount dedicated to rent/mortgage (divide Total Monthly Income by 3) $ Your MONTHLY Debt Payment: Gross Monthly Income Car Loans $ Credit Cards $ Child Support/Alimony Paid (DO NOT list if automatically deducted from paycheck) $ Medical Bills (monthly payments ONLY) $ Other (gasoline, auto insurance, church, etc.) $ Total $ Your MONTHLY Living Expenses: Monthly Expenses (full amount) Current or Proposed Rent/Mortgage (in designated field, provide associate s share if split with other household members) $ $ Utilities (electricity, natural gas, water/sanitation) $ $ Homeowners association fees or property taxes (if applicable) $ $ Food $ $ Prescriptions /medical co-pays $ $ Other (cell phone, cable, daycare/tuition, clothing, etc.) $ $ Total $ $ Monthly Debt Monthly Expenses (Associate s share) Your application IS NOT complete without our receipt of ALL relevant supporting documentation (i.e., copies of past due rent, mortgage or basic utilities). See our web site at for a complete list of required documents.

10 NEW LANDLORD STATEMENT for a complete list of required documents This form is required for all applications requesting assistance with moving into a new apartment/rental home or hotel/motel. Please have your potential landlord or apartment complex complete this form. You may also provide a similar statement on your landlord s letterhead with the appropriate information. APARTMENT/LANDLORD INFORMATION (for permanent residence) Apartment Complex Name or Landlord s Name (please print): Apartment/Rental Home Address: Apartment Complex or Landlord s Phone Number : ( ) - Anticipated move-in date: / / Apartment Rental House 1 bedroom 1 bedroom 2 bedrooms 2 bedrooms 3 bedrooms 3 bedrooms 4+ bedrooms 4+ bedrooms Total Amount Needed to Occupy Property: $ security deposit $ 1 st month s rent $ pet deposits $ other deposits (utilities, appliances, etc.) $ TOTAL Has the landlord received the security deposit? Yes No Apartment Complex/Landlord accepts: 3rd party business check certified check money order All checks for security deposit are made payable to the landlord or apartment complex only. Please make all checks payable to: / / Landlord/Complex Manager s Signature Date APARTMENT/LANDLORD/HOTEL INFORMATION (for temporary residence) Hotel/Motel s Name (please print): Hotel/Motel s Address: Daily Rate: $ Weekly Rate: $ Phone #: ( ) - Hotel accepts: third-party business check certified check money order / / Manager s Name Manager s Signature Date