To apply for assistance, please complete the application form below in its entirety CARES Application for Assistance Employee Name *Employee #Street AddressCityZip CodeHome PhoneDateDate Of BirthApt/UnitStateEmail AddressCell PhoneType of Assistance Requested (Check One)Health/Medical Education Adoption Counseling Immediate Family Emergency Property Damage Funeral Expense for Immediate Family Mission (Military -- Veteran Support, MIssion Trips) Assistance Amount Requested$Provide details, including relevant documentation, supporting your request for assistanceI hereby certify the statements above to be true and accurate.I hereby certify the statements above to be true and accurate. I authorize the Juniper Cares Employee Relief Fund Committee to review my application in consideration for financial assistance provided by the Juniper Cares Employee Relief Fund. I understand any assistance funded to me is in the form of a grant and is not payable back to the Employee Relief Fund or to Juniper, unless it is deemed that I falsified the information submitted in my application. I agree if any of the information contained within my application changes prior to receiving any assistance, I will immediately notify the Employee Relief Fund Committee in writing at firstname.lastname@example.org.By submission of my application for considerationBy submission of my application for consideration, I certify that the information in this application is true, complete, and correct. I understand that false answers, statements, or significant omissions made by me shall be sufficient cause for denial of assistance and corrective action. Should my request be approved, I agree to the terms set-forth in this application and related policies and procedures.SignatureDateIf you are completing the application on behalf of another person, please provide the following:If you are completing the application on behalf of another person, please provide the following:NameHome PhoneCell PhoneEmail AddressSubmission Process:Submission Process: Complete the application, sign, and submit to email@example.com. The Committee will review your application in accordance with the Juniper Cares Employee Relief Fund. Based upon the initial assessment by the committee, you will be referred to a Project Manager from Helping Hands Charitable who will gather basic information about your current need. The Helping Hands Project Manager shall advise the Committee of the financial need maintaining your personal information in confidence. For Committee Use Only:For Committee Use Only:Date ReceivedInitial Review ByCriteria MetYes | application forwarded to Helping Hands Grant Committee for further review. No| employee has been notified that assistance is not available at this time.