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Stories from the Midwest!


Wilimington, NC, is Raising Money for Andy's Outreach!
Andy's Outreach Submit Request
Andy's Outreach Payroll Application for Relief
If you're facing a crisis situation and need some help, here's what you need to do to submit a request to Andy's Outreach Fund:
  1. Schedule a meeting with your Managing Partner or Director to discuss your situation.
  2. Complete the on-line form below with your Managing Partner or Director, outlining your situation.
  3. Fax any bills or estimates of the costs associated to Brittany Pennington. Fax: 502-805-0639
Application for Employee Assistance
Please complete this form in its entirety. It is essential that you provide current and accurate information. Any documentation that you have that supports your claim should accompany this application to ensure there are no delays in evaluating your request. Please keep a copy of the completed form for your records.

Section 1 - Employee Information All fields marked with an asterisk (*) are required.
Legal First Name:
* 		Middle Int:
 Legal Last Name:
*
Address:
*
City:
* 		State/Prov:
* 		Postal Code:
*
*Telephone Number:
Alternate Number:
Email (if available):
*Store Name:
*Managing Parter Name/Phone Number:
*Have you applied to Andy's before?
If yes, did you receive assistance?
When Did you apply?

Section 2 - Description of Hardship
*Please check if this is a  *Date of Disaster/Financial Hardship:
(Must be triggered by an unavoidable event – illness, death, accident, crime or other personal event)
*Was it beyond your control?
*Description of Your Hardship: Please include a description of your medical expenses and/or damage to your essential property such as your primary residence or automobile.

Section 3 - Amount of Assistance Requested
*Please provide an itemized list of your assistance request:
Description Actual/Estimated Cost:
Grand Total
Amount of Assistance Requested
(Attach documentation of loss – see Section 5 for details)

Section 4 - Your Financial Resources and Other Expenses
*Please list all members of your household and their relationship to you:
Name: Relationship Age
Monthly Household Net Income, if not applicable enter "0.00":
Your Regular Net Wages/Tips * (after tax, attach year-to-date pay stub)
Other Household Wages * (after tax, attach year-to-date pay stub)
Child Support *
Social Security *
Unemployment *
Rent Assistance *
Food Stamps *
Disability *
Other *
Total Net Income:
Monthly Household Expenses:
Rent/Mortgage * (documentation may be requested)
Electric/Gas/Water *
Food *
Car Insurance *
Car Payment *
Gasoline *
Childcare *
Child Support *
Cable/Internet *
Home/Cell Phone *
Credit Card Debt *
Student Loans/Tuition *
Other Debt *
Other *
Total Expenses:
Financial Resources of Household, if not applicable enter "0.00":
Checking Account Balance *
Savings Account Balance *
Other *
Total Assets:
 
Homeowner's/Renters Insurance (complete if request is related to loss of primary residence)
Do you own or rent?
Do you have Homeowner's/Renter's insurance
If Yes, is this loss covered?
If Yes, amount of deductible?
 
Auto insurance (complete if request is automobile related)
Do you have Auto Insurance?
If Yes, is this loss covered?
If Yes, amount of deductible?
Will Auto insurance cover medical expenses?
If Yes, amount of coverage?
Will Auto insurance cover lost wages?
If Yes, amount of coverage?
 
If you are requesting temporary assistance to get to work or assistance with automobile repairs:
Is public transportation available?
Is there another car in your household?
How far is your commute to work?
 
Medical Expenses (complete if request is related to medical expenses)
Do you have Medical Insurance?
If Yes, amount of deductible $ Co-Pay $
Annual maximum out-of-pocket $
If no, amount of anticipated government assistance:
 
Assistance with Funeral Expenses (complete if request is related to funeral expenses)
Is life Insurance available?
If yes, how much?
Will funds be available from decedent's estate?
If yes, how much?
Total assistance family members can provide?
 
*Do you or any member of your household have other insurance coverage or any other financial resources to assist with the hardship? If Yes, please explain

Section 5 - Required Documentation
All of the following documentation is critical in determining the eligibility of your request and to comply with the IRS's requirement:
Income verification (required for all Requests)
  • Copy of a year-to-date pay-stub for employee and all residents of household
Initial here to authorize Andy’s Outreach to obtain pay-stub from Texas Roadhouse
Homeowners Reporting Damage to Primary Residence
  • Copy of a completed insurance claim form
  • Copies of estimate of damage and/or pictures
Renters Reporting Damage to Primary residence
  • Letter from landlord confirming damage to residence
  • Copies of estimates of damaged items and/or pictures
Automobile Owners
  • Copy of a completed insurance claim form
  • Copies of estimates and/or pictures
  • Police report for thefts/accidents
Other Incidences
  • Documentation that will validate the loss
  • Copies of estimates and/or pictures
  • Police report for thefts/domestic violence
Certification
* I have done everything possible to help myself before applying for this assistance. I certify that the information contained in this application is true, correct and complete and that I am requesting assistance because of a severe financial hardship which is not covered by insurance or any other sources. By signing the certification below, I also give Andy’s Outreach the authority to review medical information pertaining to my Application for Assistance. Medical information would include, but is not limited to, medical claims, doctors’ notes and condition prognosis/diagnosis. I also authorize Andy’s Outreach to request additional medical information as deemed necessary in the process of reviewing my request. This includes contacting any applicable care providers and negotiating with said providers on my behalf. I understand that any information used in the process of applying for Assistance may not be protected by federal privacy regulations. I also understand that this authorization is voluntary and may be revoked at any time by giving written notice of my revocation to the company contact listed in this application.
*

Once again, please remember to follow-up with your application to confirm receipt if you have not heard from Dee or Brittany within one week of submitting the application. It is our goal to process your application as quickly as possible.

Authorized Date: 2/8/2012 7:43:53 AM

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