APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA

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1 APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA PROGRAM OBJECTIVE: HOPE stands for Helping Our Peers in Emergency. It is a crisis fund supported by Scripps employees for Scripps employees. It s our way of reaching out to help someone in need. ELIGIBILTY CRITERIA: (Must meet all criteria to qualify) Full-time, Part-time, or Casual employee Employee must have worked 1,000 hours or more in the previous year Employee has been employed with Scripps no less than 180 days (approx. 6 months) Employee has not received a formal corrective action or written warning within the last six months No employee will be eligible for aid more than two times in a 24-month period during his or her employment with Scripps Health PTO hardship hours, if available, will be accessed prior to HOPE Fund approval QUALIFYING EVENTS: (Per the IRS Safe Harbor guidelines) Funeral expenses of parents, spouse, children or dependents Expenses for medical care previously incurred by the employee, the employee s spouse or any dependents of the employee or necessary for these persons to obtain medical care Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) Payments necessary to prevent the eviction of the employee from the employee s principal residence or foreclosure on the mortgage on the residence Certain expenses relating to the repair of damage to the employee s principal residence due to catastrophic casualty loss Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of postsecondary education for the employee, or the employee s spouse, children, or dependents AWARD AMOUNTS: Individual award amounts will vary, but are not to exceed $2,000 $500 may be awarded at the site level, but requires approval All requests, regardless of amount, require supporting hardship documentation. SELECTION PROCESS: Selection is based on the following (but not exclusive to) o Completion of the application o Meeting all eligibility requirements o Hardship falls within IRS Safe Harbor guidelines o Employee provides documentation of proof of hardship o Employee provides details of hardship as well as financial plan for the future APPLICATION PROCESS: Complete the HOPE Fund application in full, include all supporting documentation, and submit to your site Human Resources office. The site HOPE committee will review the request and determine eligibility and request more information, if necessary. Based on the review and findings of the committee, they will either approve or disapprove the request. o If the site committee approves: The request is submitted to payroll for the initial award of $500. The request is then forwarded to the system-wide HOPE Fund committee for further review of the remaining amount requested. o If the site committee denies: A site Human Resources representative will contact the employee with an explanation for the denial. If you have questions or need more information, contact your site Human Resources Department

2 PLEASE PRINT OR TYPE APPLICATION. So that we can process your request as quickly as possible, please complete everything on this form. This information will be given to a member of the HOPE Fund team. You will be contacted soon for more information. The information you provide will be kept confidential. It will only be reviewed by those necessary to your application process. NAME: Last First Middle Int. EMPLOYEE ID #: SOCIAL SECURITY #: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK LOCATION: DEPT: DATE OF HIRE: WORK PHONE: JOB TITLE: NUMBER OF YEARS OF SERVICE AT SCRIPPS HEALTH: CURRENT STATUS: FULL-TIME PART-TIME CASUAL TOTAL AMOUNT REQUESTED: $ DATE NEEDED: If your request is granted, do you wish to: Have your check mailed (address) Pick up check I authorize Human Resources to verify the information provided on this form. I also authorize Human Resources to gather any additional information needed by the committee to process this request. I hereby acknowledge that the attached information is correct. SIGNATURE: Date: Request For Assistance Application Rev. 1/2010 1

3 PLEASE PRINT OR TYPE APPLICATION. The following information will be reviewed by the HOPE Fund Site and/or System Committee to determine financial eligibility. The information is strictly confidential. Therefore, DO NOT list your name on pages 3 and 4. Your file will be assigned an application number for accounting purposes only. Have you received HOPE Fund or Employee Emergency Trust Fund grants previously? YES NO If yes, amount: $ Date received: Reason: Describe the nature of your hardship. Explain what led you to your current financial situation. (Please include as much information as possible to assist the HOPE Fund committee. Continue on an additional piece of paper if needed.) If your request for assistance is approved, what are your plans going forward to reconcile the hardship and prepare for the future? Please attach copies of priority bills you wish to be considered for payment. Please deliver completed application to Human Resources. Request For Assistance Application Rev. 1/2010 2

4 Please fill out as completely as possible. If supporting documents are attached for those areas marked with an asterisk*, your application may be processed more quickly. DEPENDANTS (DO NOT LIST NAMES) Relationship Age Relationship Age MONTHLY INCOME AMOUNT * Net (take home pay, provide previous 2 paystubs) $ * Workers Comp $ * State / Long Term Disability $ * Unemployment Insurance $ * Spouses Income (Include unemployment / disability / previous 2 paystubs) $ Other Sources of Income * Dependant s Income $ * Child Support $ * Alimony $ * Social Security $ * Rental Property $ * Stocks / Bonds / Dividends $ Assets Checking Acct(s) # $ Savings Acct(s) # $ Credit Union # $ Miscellaneous $ MONTHLY EXPENDITURES AMOUNT Rent / Mortgage $ Child Care $ Automobile Payments $ Food $ Gas / Electric / Phone $ Water / Trash / Sewer $ Gasoline (Auto) $ Insurance Policies Life (Premium) $ Home Owners / Auto $ Medical / Dental $ Other Expenditures Loan Payments $ Charge Cards $ Medical / Dental Bills $ Miscellaneous $ Request For Assistance Application Rev. 1/2010 3

5 THIS SECTION TO BE COMPLETED BY THE SITE COMMITTEE: DATE APPLICATION RECEIVED: DATE TO SITE HOPE REVIEW COMMITTEE: DATE TO SYSTEM HOPE REVIEW COMMITTEE: RECOMMENDED SIGNED: DENIED SIGNED: INITIAL AMOUNT RECOMMENDED: $ ADDITIONAL FUNDS RECOMMENDED? YES NO COMMENTS: CONFIDENTIAL (HUMAN RESOURCES ONLY): CHECK WRITTEN TO: CHECK NO: AMOUNT: $ DATE: NOTIFICATION GTO EMPLOYEE DATE: PHONE: EMPLOYEE WISHES CHECK TO BE: Mailed: (Address) Picked Up: (Date and Time, if applicable) Request For Assistance Application Rev. 1/2010 4