iServ Cares Application Form

iServ Cares Fund

Application for Emergency/Financial Relief

No information will be shared outside of the committee except for processing the distribution of approved
funds or for tax reporting purposes, if an award is provided. Completed application materials will be
retained by the fund.

Phone

This field is for validation purposes and should be left unchanged.

Application Information

Date of Application:(Required)

Applicant Name:(Required)

First Name Last Name

Preferred Phone #:(Required)

Home Address:(Required)

Home Address:

Email Address:(Required)

Representative Completing Application (if applicable)

Representative Name:

First Name Last Name

Relationship to Applicant:

Preferred Phone #:

Email Address:

Details of Emergency(Required)

Describe the circumstances surrounding the need for assistance. If applicable, please reference any supporting details:

If applicable, what is the dollar amount needed to work through this situation?(Required)

If applicable, what is the dollar amount needed to work through this situation?

How will the funds be used?(Required)

What, if anything, has been done thus far, by you, your family, and/or your fellow Team Members to better the situation?(Required)

Any final comments about why this application for assistance should be approved?

Applicant/Representative Certification(Required)

Please initial each of the below five statements and sign below.

I certify that the information provided is true and correct to the best of my knowledge, and that any money received will be used to relieve the stated financial hardship.

I agree to provide the Committee administering this program with documentation regarding my utilization of the award upon request.

I also understand that money received from this fund will be treated as taxable income and is a onetime award.

Any intentional misrepresentation of information contained in this application or shared during its review will result in forfeiting this and any future application for assistance, possible disciplinary action and a potential demand for repayment of funds issued.

Furthermore, I understand that the completion of this application does not guarantee funding, and that if needed I will address any concerns or questions related to my application.

Type your name(Required)

Signature(Required)

Date(Required)

Consider joining iServ on our mission.

Honor God. Honor People.

We Love
What We Do

Supporting Our Team
Members and Communities

Every Job
Is Important

Consider joining iServ on our mission. Honor God. Honor People.

We Love What We Do

Supporting Our Team Members and Communities

Every Job Is Important

Consider joining iServ on our mission.

Honor God. Honor People.

We Love
What We Do

Supporting Our Team
Members and Communities

Every Job
Is Important