Fillable A.C. Lewis Memorial Library Emergency Assistance Fund (LEAF) (Grambling State University)

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A.C. Lewis Memorial Library Emergency Assistance Fund (LEAF) (Grambling State University)

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A. C. Lewis Memorial Library
A.C. Lewis Memorial Library Emergency Assistance Fund (LEAF) – Application
The Library Emergency Assistance Fund (LEAF) is a temporary relief fund designed to help
student(s) with unforeseeable life events and hardships that could affect their life/education.
Examples of unexpected emergency situations are: life-threatening/frightening emergencies,
unanticipated emergency issues (homelessness, medical issues, job loss, etc.), and other
related issues. The funds may not be applied towards tuition, books, or other university-
related expenses. Although limited in scope, the funds could provide the assistance needed to
“help” students overcome unforeseeable events/emergencies.
Giving is living. “There is happiness, a sense of life satisfaction, and benefits of longevity in
serving and helping others. If God can do it for us, we can also do it for others.” – Anonymous
STEP 1: CAN I APPLY FOR EMERGENCY ASSISTANCE?
Please check that you have read and understand each item.
Sign here: ________________________________________
To be eligible for emergency assistance, I must:
have earned a 2.0 cumulative GPA or
be enrolled during the current semester for six (6) or more credit hours.
I understand that:
funds will not be issued to students when a 3
rd
party vendor is involved. Instead, the funds
will be issued directly to the vendor. Also, a thorough investigation will be conducted to
ensure that any funds issued directly to the students are used for the indicated
purpose(s).
dual-enrolled high school students are not eligible to receive these funds
funds will not be used for tuition, books, professional development courses, or other
school-imposed fees (parking tickets, etc.).
emergency funds cannot be transferred to other students. Only the person who applied
for and was awarded the funds is eligible to use them.
applications are reviewed throughout the year; therefore there is no deadline for applying.
STEP 2: IF YOU ARE ELIGIBLE TO APPLY FOR EMERGENCY ASSISTANCE, COMPLETE
THESE ITEMS BEFORE SUBMITTING YOUR APPLICATION:
I have completed the following tasks:
My unofficial GSU transcript is attached
I have completed the vendor information on page 3
I have attached separate documentation from the vendor to verify the amount of my
request
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signature
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2
A representative from the financial aid office has completed page 5.
My instructor has completed page 5.
STEP 3 – SUBMIT APPLICATION TO THE GSU LIBRARY
After you have read the eligibility requirements for emergency funds (step 1) and after you have
collected the necessary information (step 2), you may submit your application to the GSU
Library and schedule a meeting to discuss your request. For more information, please contact
Mrs. Jessica Gipson at 318-274-3354, grigsbyj@gram.edu, or at the Library Main Office in the
A. C. Lewis Memorial Library in Room 216.
Please complete, sign and return this application to Cecilia Iwala, Interim Director, A. C. Lewis
Memorial Library, 403 Main Street, Box 4256, Grambling, LA 71245.
STEP 4 – IF YOU ARE AWARDED EMERGENCY ASSISTANCE
Please check that you have read and understand each item.
Sign: ________________________________________
If you are awarded emergency assistance, please note:
Awards will be made based on the availability of funds and the appropriateness of the
request.
The most common mistakes applicants make are:
1. Failing to explain their emergency circumstances in sufficient depth on page 4.
2. Failing to identify a 3rd-party vendor if necessary/required to issue the award.
Applicants will be notified of the decision via e-mail.
The students are required to write a thank-you note or letter to the GSU Library. No funds will
be issued without the thank-you note or letter. If the thank-you note or letter is not received by
the given deadline, the assistance will be forfeited.
The funds will be issued directly to the vendor within ten (10) business days after the
student’s thank-you note or letter is received.
PROCEED TO PAGE 3 OF THE APPLICATION.
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3
Required Student Information
Full Name: ________________________________________________
Student ID Number: ________________________________________________
Last 4 Digits of SSN: ________________________________________________
Street Address: ________________________________________________
City, State, Zip Code: ________________________________________________
Telephone Number: ________________________________________________
E-mail Address: ________________________________________________
Marital Status: ________________________ Number of Dependents: ________
Employer name: ______________________ Your Position: __________________
Monthly Income. List below your sources of monthly income and amounts.
(Ex. Job - $400/week, Child Support - $75/week, etc.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Expenses. List below your monthly expenses and amounts (rent, mortgage, utilities,
food, gas, car insurance, etc.):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Required Vendor and Relevant Information
Description of Request: ___________________________________________
Amount of Request: ___________________________________________
Vendor Name: ___________________________________________
Vendor Street Address: ___________________________________________
Vendor City, State, Zip Code: ___________________________________________
Vendor Telephone Number: ___________________________________________
Account Number (if applicable): ___________________________________________
*Please attach a copy of the documentation related to and verifying
your request (copy of ID, pay stubs and related income
documentation, bills and related expense documentation, etc.). It is
important for GSU students to apply for emergency assistance when
necessary. The emergency assistance program is primarily based on need.
4
Please provide an explanation of your exceptional need/circumstances below and
why this assistance is needed (attach additional paper if necessary):
By signing below, I certify that the information on this application is complete, true and
correct and I am in need of this funding to continue my education at GSU. I understand
that if I provide inaccurate information, I will be required to repay the money and will not
be awarded Library assistance in the future. I understand I must notify the Financial Aid
Office if I drop/audit any classes during the semester which I apply.
I authorize the release and full disclosure of any and all information, including
information of a confidential and/or privileged matter, to any representative of Grambling
State University. I hereby release you, your organization, and others from liability or
damage which may result from furnishing the information requested.
I authorize the release of biographical information for use in publicity related to the
assistance program to help/encourage others to apply. I understand that anything I write
as part of my emergency assistance application may be shared with the assistance
donor(s) and/or used in conjunction with College and GSU Library materials.
I understand that I must attend a meeting with the LEAF Committee in order to be
considered for the funds. If I do not attend the meeting, my application will be
withdrawn. I must also attend the Appreciation Luncheon in the spring at the GSU
Library, and I may be asked to serve as an ambassador, volunteer, or representative of
the Library at events during the year.
_______________________________ ________________________________
Student Signature Date
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5
Student must have these sections completed
by the following departments and/or individuals
GSU Financial Aid Office Verification
Yes
No
Yes
No
Yes
No
_________________________________ __________________________________
Signature of Financial Aid Office Employee Date
_________________________________
Printed Name
Instructor Recommendation
Does the student attend classes on a regular basis?
Yes
No
Are you aware of the student’s emergency situation?
Yes
No
Do you recommend the student for an emergency assistance?
Yes
No
___________________________________ _______________________________
Signature of Instructor Date
___________________________________
Printed Name
Comments:
Please contact Mrs. Jessica Gipson at 318-274-3354, grigsbyj@gram.edu, or at the
Library main office in the A. C. Lewis Memorial Library in Room 216 to schedule a
meeting.
Print
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signature
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signature
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6
The Library has the following emergency assistance fund:
A. C. Lewis Memorial Library Emergency Assistance Fund (LEAF)
In 2015, an individual established the A. C. Lewis Memorial Library Emergency
Assistance Fund to help students cope with critical emergency needs. The fund allows
GSU students to apply for monies to be used immediately in the event of an emergency.
Part-time and/or full-time GSU students may apply for these funds.
For Library Use Only
Library Meeting:
Did the student schedule and attend a
meeting?
Yes
No
Meeting date:
Funding Decision:
Did the student legitimize his or her financial
need?
Yes
No
Will the student serve as a good
ambassador for the Library?
Yes
No
Amount Awarded
Decline Request
Additional Comments:
Decision made by:
Signature:
Date:
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A.C. Lewis Memorial Library Emergency Assistance Fund (LEAF) (Grambling State University)

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Completed 8 February 2021

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