Permobil EAF APPLICATION FOR ASSISTANCE

Employee Assistance Fund (EAF)
APPLICATION FOR ASSISTANCE
THE PROGRAM: This Fund helps employees who are experiencing economic hardship and are unable to afford housing, utilities, and other basic living needs because of a natural disaster; life-threatening illness or injury; death or other catastrophic or extreme circumstances beyond the employee’s control.

ELIGIBILITY: All Permobil employees who are 1) currently employed by Permobil; 2) in good standing with Permobil; and 3) past the 90-day introductory probationary period are eligible to apply for The Permobil EAF. Temporary employees are not eligible to apply. An employee can only be approved for assistance once within a 12-month period.

GRANTS: The maximum grant amount available for assistance is $1000.00.
The maximum award is not guaranteed. Payments are typically made directly to vendors as bill payments and applicants will not be reimbursed if they pay the vendor directly.

Permobil Foundation staff is available to assist all applicants with this process.
Email EAF@PermobilFoundation.org to schedule a time.
SECTION A: WILL YOU QUALIFY?
To qualify for this program and receive assistance you must meet all 3 of these requirements

You must be currently employed by Permobil or its subsidiaries and have been employed at Permobil or its subsidiaries at the time of the incident.The qualifying incident must have happened within the past 60 days.Your situation MUST fall into one of these three categories: (check the one below that describes your situation)
Check one that best describes your situation*

Natural Disaster: situations such as a wildfire, flood, tornado, hurricane, severe storms or earthquake, that have damaged or destroyed the employee’s primary residence. The Fund cannot pay to repair other property fencing, garages, storage buildings, etc and cannot pay to replace non-essential items, such as electronics or furnishings. Photographs, insurance reports, or other documentation of damage will be required.Life-Threatening Or Serious Illness Or Injury: the employee suffers a serious or life-threatening illness or injury that causes economic hardship. The Fund is not a substitute for medical insurance and is not intended to cover insurance deductibles. In order to qualify under this type of situation the injury must result in financial need, including an inability to pay basic living expenses. Medical documentation will be requiredCatastrophic or Extreme Circumstances: This includes but is not limited to: fire, major home damage (not caused by natural disaster) that could not be prevented, serious crime against the employee (robbery, arson, assault, domestic abuse, extreme vandalism), Presidentially declared disaster (such as Covid-19), or another reportable incident beyond the applicant’s control that impacts the ability to afford basic needs. Catastrophic or extreme circumstances do not include: a layoff or furlough, credit card debt, home foreclosure, wage garnishment, child support payment, car repair, taxes, or accumulated debt, among other things. Police, Fire or other official incident report will be required.
SECTION B: YOUR GENERAL INFORMATION
Applicant/Employee Name (please print clearly):
Email: Approval notification is sent to your email, so please provide an email you regularly check.
example@example.com
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone (including area code)
xxx-xxxx-xxxx
Is it okay to leave you a message on this phone?

YESNO
Other Phone (including area code)
xxx-xxxx-xxxx
Is it okay to leave you a message on this other phone?

YESNO
Current Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Hire:

MonthDayYear
Date
Job Title:
Supervisor Name:
SECTION C: DESCRIBE YOUR SITUATION

Which qualifying situation caused the financial hardship? Read the descriptions above on page 1 in Section A then select the category below that best fits your situation. (Email EAF@PermobilFoundation.org with questions)
Select which best describes your situation:

Natural DisasterLife Threatening Illness or InjuryCatastrophic or Extreme Circumstance
Type of Incident
(example: tornado, fire, flood, type of injury, name of illness, domestic abuse)
Date of Incident:

MonthDayYear
Date must be within the past 60 days
Who has been affected by the situation?
Is the affected person covered by medical or disability insurance?
Have they applied for disability benefits
If your home was damaged, will insurance cover part of the cost?
Your deductible amount?
How many people live in your household?
Number of adults
Number of children
Describe the incident in detail. What happened?
Describe how the incident has caused your financial hardship. How has this made it hard to afford your basic living needs?
Estimate the financial impact of the incident. How much has this cost you?
Please tell us anything else that would help us understand the hardship you or your family are experiencing.
Have other resources been considered or used, such as American Red Cross, Salvation Army, local faith organizations, your state 2-1-1 referral service, or other, similar social services agencies? Describe those efforts and the response you received.
SECTION D: ASSISTANCE GRANTS
Grants are only to help pay for limited types of essential living expenses, which are:
- Rent, mortgage or other housing payments
- Temporary housing and security deposits for new/temporary housing incurred during incident
- Essential utility bills (electricity, heat, water)
- Medical expenses incurred within past 60 days related to the incident and not covered by insurance
- Minor home repairs needed to maintain home safety and livability
Grants cannot be made to pay for other, non-essential expenses such as:
- Insurance premiums or deductibles
- Cable, phone or internet service
- Car payments, repairs or car insurance
- Furniture, appliances, electronics
- Funeral expenses or grave markers
- Accumulated financial issues or credit card debt
- Accidental damages due to negligence
- Legal fees, legal fines or court costs
If the application is approved, payments will typically be made on your behalf to the vendor(s) you list. Grants are paid directly to vendors as bill payments and you will not be reimbursed if you pay the vendor directly. A letter will be emailed to you listing all payments made on your behalf including the amount and date sent.

Provide the name of the vendor to be paid, the complete address, the account number or identifying information, amount due, and due date. The maximum grant amount is $1000.00, so list the vendors in order of priority. For each vendor, attach appropriate documentation (bills, lease, mortgage coupon, statement, etc

NOTE : We cannot make payments without clear, complete information including full account numbers or other payment information, addresses and documentation. Omitting this information or copies of your bills will delay your application.
Vendor/Biller Name #1
Complete Mailing Address for Payment
Basic Need Covered
What is it for?
Payment Amount
Payment Due Date

MonthDayYear
Date
Account Number or Identifying Information
Upload/Attach Vendor #1 bill or statement or invoice here

Browse Files

Cancelof
Vendor/Biller Name #2
Complete Mailing Address for Payment
Basic Need Covered
What is it for?
Payment Amount
Payment Due Date

MonthDayYear
Date
Account Number or Identifying Information
Upload/Attach Vendor #2 bill or statement or invoice here

Browse Files

Cancelof
Vendor/Biller Name #3
Complete Mailing Address for Payment
Basic Need Covered
What is it for?
Payment Amount
Payment Due Date

MonthDayYear
Date
Account Number or Identifying Information
Upload/Attach Vendor #3 bill or statement or invoice here

Browse Files

Cancelof
SECTION E: DECLARATIONS AND AGREEMENT
No employee is entitled to receive a grant based on their employment. Grants will not be made before an employee has demonstrated an immediate financial need and provided all required documentation.

This application will be treated in a confidential manner by the Permobil Foundation Board of Directors and one member of the Permobil Human Resource Department (based on your location); however non-identifying statistical information will be reported to Permobil on a periodic basis.

Employees are expected to provide truthful and accurate information. In its due diligence, if the Permobil Foundation discovers any information to be untrue, it shall have the right to unilaterally waive its confidentiality and report its findings to Permobil. The fiduciary expectations of the Permobil employees are paramount and a breach of these standards will be reported to Permobil.

Your signature below certifies that the information provided is true and complete, authorizes The Permobil Foundation to obtain and/or verify all information necessary to process this application, and releases Permobil and the Permobil Foundation from any liability associated with the rejection of or funding of this application. Submission of this application does not defer your responsibility to make payments and it is recommended that you communicate with your vendor. Remember that the maximum amount any employee or family member can receive in a 12-month period is $1,000. It is likely that, from time to time, lesser amounts will be awarded. In addition, you agree to provide the requested documentation supporting the information provided.
Applicant's Signature:

Clear
Date:

MonthDayYear
Date
Upload Required Documents

If you have have more documents to upload than space allows, please contact us: EAF@PermobilFoundation.org for further instruction
Please upload copies of required documentation here (medical, police & fire reports, ect

Browse Files

Cancelof
Upload other information you would like to include

Browse Files

Cancelof
Application Checklist:
Did you remember the following:

Carefully read the requirements to see if you qualifyComplete Sections A-D of the applicationCheck Section D that your grant requests are allowed by the programSign Section E: Declarations and Agreement pageUpload/Attach copies of documentation such as: bills, leases, mortgage coupon or statementInclude all required documentation medical, police & fire reports, etc
Please click the submit button below and the Permobil Foundation will alerted. We will contact you very soon.
Should be Empty:

Employee Assistance Fund (EAF)

APPLICATION FOR ASSISTANCE

SECTION A: WILL YOU QUALIFY?

SECTION B: YOUR GENERAL INFORMATION

SECTION C: DESCRIBE YOUR SITUATION

SECTION D: ASSISTANCE GRANTS

SECTION E: DECLARATIONS AND AGREEMENT

Upload Required Documents

Application Checklist:

Please click the submit button below and the Permobil Foundation will alerted. We will contact you very soon.