Application for Financial Assistance - Association of the Wall and Ceiling Industry

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Instructions

Applicant Information
- Name and complete contact information.
- If the applicant has legal dependents, this section must be completed.
Employment Information
Reason for Applying
Funding Requests
Other Sources of Financial Support
Financial Information
Health Insurance and Medical Information
Authorization
Employer Must Complete and Submit Company Verification Form
- This form needs to be completed by the applicant’s immediate supervisor, company owner or human resource department.
Please reach out to AWCI CARES with any questions about the application or process.

Employee/Applicant Information

MUST BE CURRENTLY EMPLOYED BY AN AWCI MEMBER COMPANY IN GOOD STANDING

Name*

First Last

Address*

Street Address City State ZIP Code

Email*

Cell Phone*

Work Phone*

Sex*

Male

Female

Date of Birth*

MM slash DD slash YYYY

Please select month and year before selecting date.

Marital Status*

Single

Married

Partner

Separated

Divorced

Widowed

Do you have legal dependents?

Yes

Legal Dependents of Applicant*

Name

Date of Birth

Relationship to Applicant

To add more than one legal dependent, click the + icon.

II. Employment Information

Company Name*

Company Location*

Date of Employment From*

MM slash DD slash YYYY

Date of Employment To

MM slash DD slash YYYY

Please leave blank if still working.

Job Title / Occupation*

Supervisor's Information

Supervisor's Name*

First and Last

Job Title*

Email*

Phone*

If not currently working, date expected to return to work:

MM slash DD slash YYYY

III. Reason for Applying

For CARES to evaluate the application and financial need, please describe, in detail, the immediate need, circumstances and related financial hardship.*

IV. Funding Request

Please indicate the total amount of dollars you are requesting:*

Specify emergency financial needs by listing amounts and creditors below. Copies of bills/invoices must be attached and submitted with this application. All invoices submitted must be the most current/recent amounts due.

Itemized Details*

Amount

Description

Creditors

To add more than one item, click the + icon.

All grants awarded are paid directly to creditors, not applicants.

V. Other Sources of Financial Support

Please add in all relevant information.*

AWCI CARES was created to provide financial assistance for individuals and their families that are experiencing an emergency financial hardship. As part of the application evaluation process, please provide information on any other sources of assistance that you have received related to this emergency financial hardship and the type and level of assistance that you received.

Types of assistance include:

Your employer, co-workers, family, and friends
Federal, state, and local government agencies (e.g. FEMA, unemployment benefits, SNAP, etc.)
Non-profit organizations
Crowd funding sources (e.g. GoFundMe, Kickstarter, CrowdRise, Facebook, etc.)

VI. Financial Information

Complete all sections to the best of your ability.
If it is zero in value, enter $0.00.

Estimated Monthly Family Expenses

Household/Family Assets

Rent/Mortgage:*

Checking/Savings (including CDs, Money Markets, Stocks, Bonds, etc.):

Health Insurance:*

Retirement (e.g., 401K, IRA, etc.):

Utilities/phone:*

Additional Home/Real Estate:

Other Monthly Expenses (e.g., transportation, food, childcare, etc.):*

Life Insurance (if applicant is deceased):

Medical bills:*

Other:

TOTAL*

TOTAL

Check All Other Regular Sources of Monthly Income*

Retirement (e.g., Social Security, 401K, Pension, etc.)

Salary

Unemployment

Alimony

Public Assistance

Short Term Disability

Child Support

SSD (Social Security Disability)

SSI (Supplemental Security Income)

Other Company Benefits

Other Household Income

None

Please indicate the monthly amount from each source of income. Example: Salary: $1,000

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Please Indicate Monthly Amounts from Each Source of Month Income. Write N/A if not applicable.

Please indicate the monthly amount from each source of income. You may click the "+" to add more lines. Example: Salary: $1,000

Monthly Retirement Income