Application for Assistance The American Airlines Family Fund is a public, nonprofit 501(c)(3) organization that provides financial assistance to employees of American Airlines and its wholly own subsidiaries, or their families, who are facing sudden and unexpected catastrophic situations that threaten their health and welfare. Requests for assistance are processed without regard to race, religion, national origin, age or sexual orientation. By submitting this request for assistance, applicants expressly authorize Family Fund to verify all information contained in the application, and initiate discussions with current or former coworkers, supervisors, neighbors, physicians, attorneys, and other persons. Family Fund understands that this verification and review process may deal with information that is personal in nature and promises to treat all such information in a confidential manner, to the extent possible and within the limitations specified above. In all circumstances relative to this application, Family Fund shall mean its officers, directors, managers, committee members, volunteers or agents. Family Fund recognizes that most applicants are dealing with very difficult and challenging situations, however not all requests will meet the minimum criteria to qualify for assistance. Applicants should understand that criteria and maximum grant amounts may change from time to time and without notice and that approval of an application is based upon the criteria in force at the time the application is reviewed. Minimum general criteria for grant approval includes, but is not limited to, the following:
The event causing the emergency occurred within six (6) months of submitting the application The request is for short-term, crisis relief assistance The event causing the emergency was sudden and unexpected Circumstances threaten health and welfare The situation developed / continues through no fault of the applicant Personal resources have been leveraged or are being fully utilized
The current maximum grant amount is $2,500. This amount is subject to change without notice. Applications are accepted with the understanding that all statements and information supplied are true and accurate. False statements will be cause to disqualify the request. Submission of an application is voluntary and does not guarantee favorable acceptance. In order for your application to be reviewed, it must be completed in full and all required documentation attached. Applications that are incomplete, contain inconsistencies, errors, partial responses, or lack the required supporting documentation will be returned. Revised: December 2015
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Applicant / Employee Information
Date (mm/dd/yy)_____________________________
Office Use Only
Personal Information Applicant’s Name _________________________
Relation to Employee _________________________
Employee’s Name _________________________
Employee Number ___________________________
Home Street ___________________________________________________________________________________ City, State, Zip _________________________________________________________________________________ Home Phone _____________________________
Cell Phone __________________________________
Work E-mail______________________________
Home E-mail ________________________________
Date of Birth (mm dd yy) ______________________ Marital Status ______________________________
Number of Dependents (not including self) ________
In the space below, identify all dependents you currently support. Name
Relationship
Age
1. _________________________________
____________________________
______________
2. _________________________________
____________________________
______________
3. _________________________________
____________________________
______________
4. _________________________________
____________________________
______________
5. _________________________________
____________________________
______________
6. _________________________________
____________________________
______________
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Employment Information Current Employer _________________________
3 Digit Station Code __________________________
Department ______________________________
Employment Status __________________________
Work Phone ______________________________
Work E-mail ________________________________
Seniority Date (mm dd yy) ___________________
Length of Employment (yrs / mos) ______________
What shift / days do you normally work? ____________________________________________________________ Are you working your usual schedule or reduced hours?
Employment Contact (Please provide your immediate supervisor’s contact information) Name ____________________________________
Work Phone ________________________________
Work E-mail _______________________________
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Circumstances Relating to the Emergency Please answer each of the following questions completely. Applications with unanswered questions may be returned. Providing complete details is the best way to ensure the Grant Committee understands the circumstances of your situation. This event must be within six months of this application.
Have you requested assistance from the Family Fund in the past? If yes, provide the following information: Date of Request _________________________
If Approved, Amount Received _________________
Event Causing the Current Emergency Event Date _____________________________ 1. Describe the event that caused your situation.
2. If the event is medical, please describe your treatment including all prescribed medication.
3. Are you under the care of a licensed physician? Please include a diagnosis / treatment statement from your physician.
3. Specifically describe the short-term, crisis relief assistance you are requesting (i.e. help with rent/mortgage, car payment, medical payments, etc.).
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4. Does your spouse, partner, or others contribute to the household expenses? If yes, provide the amount of contribution. If not, please explain why.
5. List all other appeals for assistance you have made to family, friends, church, WINGS, Red Cross, United Way, etc. Provide dollar amounts and dates.
7. State whether workman’s compensation benefits have been claimed, the total number of weeks, amount received, and payment dates.
8. State whether any insurance and disability payments or any other financial assistance related to this emergency have been received. Provide payment amount and dates.
9. If you have filed a report relating to this emergency with insurance companies, governmental or law enforcement agencies, or your employer, please list it here and then attach a copy of the report. (Examples: police, fire, accident report).
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Income Sheet* *Base income does not include overtime. In the spaces below, indicate your monthly income BEFORE and AFTER the emergency. NOTE: Applicant and spouse / partner must each attach at least two pay-stubs - one within 30 days before the emergency and the other within 30 days after the emergency.
Monthly Income BEFORE the Emergency Applicant Base Income After Taxes Spouse / Partner Base Income After Taxes Alimony Child Support Retirement 401(k) / Pension Social Security Benefits Short / Long Term Disability State Assistance / Food Stamps Worker’s Compensation Other Income _______________________ Other Income _______________________ Total Monthly Income
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Monthly Income AFTER the Emergency
Expense Sheet In the spaces below, indicate your monthly expenses BEFORE and AFTER the emergency. In EVERY instance that a past due balance is indicated following the emergency, a copy of the monthly vendor statement must be attached. BEFORE the Emergency Monthly Expenses
Past Due Balances
Alimony Auto Insurance Auto Loans Cable TV Child Care Child Support Clothing Credit Cards Electric Gas Groceries Homeowner / Renter Insurance Loans (Misc) Medical / Dental Medical Insurance Rent / Mortgage Telephone Water Other Income Other Income Total Monthly Expense
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AFTER the Emergency Monthly Expenses
Past Due Balances
Balance Sheet Summarize assets and liabilities below. Use the space Description to briefly describe the item. • Market Value is the fair and reasonable price for which the item can be sold. • Current Liability is the outstanding balance or amount currently owed for the asset. • Equity balance is the difference between the Market Value and Current Liability.
Type
Description
Market Value
Current Liability
Equity Balance
Auto 1 (Year & Make) Auto 2 (Year & Make) Boat (Year & Make) Cash-on-Hand Checking Balance(s) Income Property (Type) Mutual Funds Residence Retirement Account(s) Savings Balances(s) Stocks / Bonds Other (Specify) Other (Specify)
Year of your most recent IRS tax filing ______________________________________________________ NOTE: Attach a copy of “page 1” of this tax document.
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Assistance Request Details Family Fund grant criteria and maximum grant amount may change without notice. Grant approval and amount are based on the criteria at the time the application is reviewed by the Grant committee. If approved, payment can only be made to a vendor or service provider upon receipt of a current statement or invoice within the past 30 days. Each invoice must be $50 or greater. All bills, including contracts and leases must be in the applicant’s name. Assistance pertaining to any legal issues, i.e. attorney fees, etc. is not eligible for assistance from the Family Fund. List the number of months and amount of assistance below.
# Months
Amount
Car Insurance Car Payment Doctor Bill (after insurance payment) Electric Gas Health Insurance i.e. PayFlex / Cobra Hospital Bill (after insurance payment) Primary Phone Rent / Mortgage Water
Total of Above $ ____________
Amount you are requesting from Family Fund $___________
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Total
Ready to Submit? Supporting documentation must be attached to your application. If your application is incomplete or without the required documentation listed below it cannot be processed and may be returned.
Check the list below to make sure you have included all necessary items. Please note all items listed below may not apply to every situation. Items with a * are required for all applications. Supporting document is required for all applications but will vary depending on your situation.
1. ____ Completed Application for Assistance including acknowledgement page* 2. ____ Two pay stubs, employee / spouse / partner each, for before and after the emergency.* 3. ____ First page of the most recent tax filing for employee / spouse / partner* 4. ____ Medical documentation and support for health event including doctor’s notes, office visit bills, hospital bills, etc. 5. ____ Short-term disability/Long-term disability / Social Security statements / Check stubs 6. ____ Police / Accident report / Insurance / Fire report 7. ____ FEMA / Red Cross assistance documentation (for natural disasters) 8. ____ Mortgage statement / rental or lease agreement* 9. ____ Copies of invoices for which assistance is requested (current, in applicant’s name)*
Submission Instructions After completing this application, print, make a copy for your records, and submit to: Mail:
American Airlines Family Fund 4333 Amon Carter Blvd MD 5575 Ft Worth, TX 76155
Scan:
[email protected]
Fax:
(817) 967-9784
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Acknowledgement Page Upon completion of application, please sign and date below. Refer to checklist on page 10 to make sure all necessary items are submitted with your application.
Applicant Acknowledgement: I attest that the information furnished in this application is true and accurate to the best of my knowledge and belief.
Employee Statement (if applicant is not the employee): I attest that I am a current or former American Airlines employee, or an employee of one of American’s wholly owned subsidiaries. I further state that if the applicant is a member of my family, he or she is applying for assistance from the Family Fund with my knowledge and approval. I attest that the information furnished in this application is true and accurate to the best of my knowledge and belief.
Employee Statement: In applying for assistance from the American Airlines Family Fun d, I acknowledge and agree to be bound by these terms and conditions by my signature below.
Employee Name __________________________________________________________________
Signature________________________________________________________________________
Employee Number_________________________________
Date____________________________________________
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