Good Samaritan Project

Hardship Assistance Application

This application is for employees facing a genuine hardship involving basic needs such as housing, utilities, food, transportation, or a medical/family crisis. Assistance is not guaranteed and is subject to review and approval. Fields marked * are required.

Before you begin:

Please start this request with your General Manager, who should confirm your basic eligibility before submitting. Employees must have worked for the company at least 12 months and be regularly working scheduled shifts.

EMPLOYEE INFORMATION

First Name(Required)

Last Name(Required)

This field is hidden when viewing the form

Employee ID / POS Number

This field is hidden when viewing the form

Date of Hire(Required)

Phone Number(Required)

Email Address(Required)

Store / Location(Required)

Position / Role(Required)

TYPE OF ASSISTANCE REQUESTED

What kind of assistance are you seeking?(Required)

Non-interest loan

Community resource referral

Counseling / guidance

Unsure — please advise

If assistance is provided as a non-interest loan, you will be required to complete a budget review, sign all required loan documents before funds are issued.

NATURE OF HARDSHIP

Category of Hardship(Required)

Housing (rent, eviction notice, mortgage)

Utilities (disconnection notice, past-due bill)

Food / basic necessities

Transportation (car repair, insurance lapse)

Medical / family crisis

Other urgent situation (describe below)

Describe your situation(Required)

DOCUMENTATION

Supporting documentation strengthens your request. Examples: rent notice, utility bill, eviction notice, car repair estimate, medical bill. Lack of documentation may delay or prevent assistance.

Documents you are able to provide(Required)

Rent or mortgage notice / eviction notice

Utility disconnection notice or past-due bill

Car repair estimate or bill

Medical bill or statement

SELF-CERTIFICATION

Please confirm each of the following(Required)

I have worked for the company for at least 12 months.

I am currently working my regularly scheduled shifts.

I have completed all required HUB or employer-required training.

I have spoken with my General Manager about this request.

I am not requesting assistance for credit card debt, payday loans, or non-essential purchases.

I am willing to engage with outside resources if referred.

EMPLOYEE ATTESTATION

By signing below, I confirm that the information provided is truthful and accurate to the best of my knowledge. I understand that assistance is not guaranteed and is subject to review and approval by the program director. Providing false information may result in denial and/or disciplinary action. If a loan is approved, I agree to complete all required documentation within 30 days after funds are issued.

Signature(Required)

Date(Required)

GENERAL MANAGER

GM Name(Required)

GM Phone(Required)

GM Email(Required)

CAPTCHA