Request Form

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 the Andy’s Outreach Fax Number: 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.

Applications with supporting documentation must be submitted by Tuesday at midnight to be considered for weekly disbursement committee review. Emergency situations will be reviewed in a timely manner.

Section 1 – Employee Information

*First Name M.I.

*Last Name

*Home Address

*City *State *Zip

*Phone Number Alternate Number

Email

*Store Location Store Number

*Managing Partner Name

Managing Partner Number

*Have you applied to Andy's before?  Yes No

*If so, did you receive assistance?  Yes No First time applying

When did you apply? //

Section 2 – Description of Hardship

*Please check if this is a  Natural Disaster Financial Hardship

*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?  Yes No

*If able to work, have you requested additional shifts, with your manager to assist with your hardship?  Yes No

*Have you applied for or are you receiving any short/long term disability benefits?
 Yes No

If yes, please explain:

*Do you or any member of your household or family have other insurance coverage or any other financial resources to assist with the hardship?  Yes No

If yes, please explain:

*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 Income
*Your Regular 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:  
Monthly Household Expenses
*Rent/Mortgage: (documentation may be requested)
*Electric/Gas/Water: (after tax, attach year-to-date pay stub)
*Food:  
Car Insurance:  
Car Payment:  
Gasoline:  
Childcare:  
Child Support:  
Cable/Internet:  
Home/Cell Phone:  
Household/Personal Care:  
Credit Card Debt:  
Student Loans/Tuition:  
Other Debt:  
Other:  
*Total:  
Financial Resources of Household
Checking Account Balance:
Savings Account Balance:
Other:
Total:

Are you interested in receiving information regarding budget planning?
 Yes No

Homeowner’s/Renter’s Insurance
(complete if request is related to loss of primary residence)

Do you own or rent?  Own Rent

Do you have Homeowner’s and/or Renter’s Insurance?  Yes No

If yes, is this loss covered?  Yes No No Insurance

If yes, amount of deductible:

Is the loss due to a federally declared natural disaster?  Yes No

If yes, have you applied for FEMA assistance?
 Yes No Not federally declared national disaster

Amount of anticipated assistance:

Auto Expenses
(complete if request is automobile related)

Do you have Auto Insurance?  Yes No

If yes, is this loss covered?  Yes No No Insurance

If yes, amount of deductible:

Will Auto Insurance cover medical expenses?  Yes No

If yes, amount of coverage?

Will Auto Insurance cover lost wages?  Yes No

If yes, amount of coverage:

If you are requesting temporary assistance to get to work or assistance
with automobile repairs:

Is public transportation available?  Yes No

Is there another car in your household?  Yes No

How far is your commute to work?

Medical Expenses
(complete if request is related to medical expenses)

Do you have Medical Insurance?  Yes No

If yes, amount of annual deductible:

Co-pay per visit:

Annual maximum out-of-pocket:

If no, amount of anticipated government assistance:

Have you applied for financial assistance through your medical provider and/or hospital?
 Yes No

If yes, amount of anticipated assistance:

Assistance with Funeral Expenses
(complete if request is related to funeral expenses)

Is Life Insurance available?  Yes No

If yes, how much?

Will funds be available from decedent's estate  Yes No

If yes, how much?

Total assistance to family members can provide

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 requirements:

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 & Release

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 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.

I understand that the Disbursement Committee may contact my Managing Partner or Director for additional information regarding my application, and that it may be necessary for the committee to share certain details regarding my application with that person.

//
*Employee Signature (or Delegate) *Date
*Printed Name Relationship

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