Form CARES Application for Assistance

To apply for assistance, please complete the application form below in its entirety

Application for CARES Assistance

EMPLOYEE NAME *

EMPLOYEE # *

DATE *

DATE OF BIRTH *

HOME PHONE

CELL PHONE

STREET ADDRESS

APT/UNIT

CITY

STATE

ZIP CODE

EMAIL *

Type of Assistance Requested (Check one)
EducationAdoptionCounselingImmediate Family EmergencyProperty DamageFuneral Expense for Immediate FamilyMission (Military -- Veteran Support, Mission Trips)

Assistance Amount Requested

Provide details, including relevant documentation, supporting your request for assistance

I hereby certify the statements above to be true and accurate. I authorize the Juniper Cares Employee Relief Fund Committee to review my application in consideration for financial assistance provided by the Juniper Cares Employee Relief Fund. I understand any assistance funded to me is in the form of a grant and is not payable back to the Employee Relief Fund or to Juniper, unless it is deemed that I falsified the information submitted in my application. I agree if any of the information contained within my application changes prior to receiving any assistance, I will immediately notify the Employee Relief Fund Committee in writing at caresfund@juniperlandscaping.com

By submission of my application for consideration, I certify that the information in this application is true, complete, and correct. I understand that false answers, statements, or significant omissions made by me shall be sufficient cause for denial of assistance and corrective action. Should my request be approved, I agree to the terms set-forth in this application and related policies and procedures.

SIGNATURE *

DATE *

If you are completing the application on behalf of another person, please provide the following:

NAME

HOME PHONE

CELL PHONE

Submission Process:

Complete the application, sign, and submit to caresfund@juniperlandscaping.com.
The Committee will review your application in accordance with the Juniper Cares Employee Relief Fund. Based upon the initial assessment by the committee, you will be referred to a Project Manager from Helping Hands Charitable who will gather basic information about your current need.
The Helping Hands Project Manager shall advise the Committee of the financial need maintaining your personal information in confidence.

For Committee Use Only:

DATE RECEIVED

INITIAL REVIEW BY

Criteria Met

Yes. Application forwarded to Helping Hands Grant Committee for further review.No. Employee has been notified that assistance is not available at this time.