Fillable Emergency Fund App2014 (University of West Florida)

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Emergency Fund App2014 (University of West Florida)

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Date: Case #:
STAFF SENATE EMERGENCY ASSISTANCE FUND
_____________________________________________________
CONFIDENTIAL EMERGENCY ASSISTANCE PROGRAM APPLICATION
I. APPLICANT’S PERSONAL DATA
Name:
UWF ID#:
Marital Status:
Spouse Name:
Dependents:
Home Address:
Home Phone/Cell Phone:
Department:
Supervisor:
II. DETAILED DESCRIPTION OF NEED:
Use back of form if necessary. Supporting documentation must be included with the
application or IT WILL BE RETURNED TO YOU FOR COMPLETION.
Date: Case #:
III. REFERENCES FOR VERIFICATION OF NEED (At least two):
1. Name:
Address:
City/State/Zip Code:
Telephone:
Relationship:
2. Name:
Address:
City/State/Zip Code:
Telephone:
Relationship:
3. Name:
Address:
City/State/Zip Code:
Telephone:
Relationship:
Date: Case #:
IV. COMMITTEE RECOMMENDATION:
APPROVED: DISAPPROVED:
Amount exceeds $500/Staff Senate Executive Committee Decision:
APPROVED: DISAPPROVED:
REASON:
V. COMMITTEE MEMBER SIGNATURE(S):
______________________________________________
______________________________________________
Date: Case #:
FINANCIAL ANALYSIS CHECKLIST
NUMBER IN HOUSEHOLD:
I. BASIC MAINTENANCE
DESCRIPTION AMOUNT DUE COMPANY OWED DATE DUE
a. Rent/Mortgage
b. Electric
c. Gas
d. Water
e. Cable/Internet/Phone
f. Insurance
g. Transportation
(Work only-gas/car payment)
h. Food
i. Child Care/Child Support
TOTAL
II. INCOME SOURCES
SOURCES PERIODIC RECEIPTS ($)
a. (salary)
b. (other)
c. (other)
TOTAL
III. OTHER ASSETS:
BANK ACCOUNT BALANCE TYPE OF ACCOUNT
a.
b.
c.
TOTAL
IV. OTHER: (INSURANCE)
INSURANCE CO. VALUE DEDUCTIBLE
a. (car)
b. (house)
c. (other)
_____________________________________________ __________________
SIGNATURE OF ELIGIBLE EMPLOYEE DATE
$ 0.00
$ 0.00
$ 0.00
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Emergency Fund App2014 (University of West Florida)

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Completed 20 July 2020

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