Request for Benefit Verification

By completing this form, you will send an automatic email to your consumer's case manager asking them to complete the Hardship PTO Verification form. This form is required for you to receive your COVID-19 Hardship PTO benefit.

Please note that the Trust does not guarantee the privacy of information that you or your consumer’s case manager submit to the Trust using JotForm. If you have any concerns regarding the use of JotForm to provide this information, you may instead contact your consumer’s case manager through email, phone, or other means, and request that they complete the Benefit Verification Form available on the Trust website: orhomecaretrust.org/hardship-pto.

Dear local office,

I recently suffered a loss of work hours due to COVID-19, and submitted a Hardship PTO Benefit Request Form to the Oregon Homecare Workers Benefit Trust. 

In order to verify my loss of hours, please click here to complete the Hardship PTO Benefit Verification Request Form.

You will need the following information to complete the form:

Thank you for helping me apply for this benefit in a timely manner.

Sincerely,