Last Name *

First Name*

Address

Home Telephone Number *

Cell Phone Number *

Email Address *

Community Name *

Position *

I request a grant from Benchmark One Company Fund and by signing this application confirm that the information contained in the attached request for Emergency Assistance and attachments is true, correct and complete.

I also authorize Benchmark Assisted Living to release information concerning my employment, wages, good standing and job history to One Company Fund, which will be used to determine eligibility.

Yes, I authorize the sharing of my story, name, photo and assistance received.
Yes, I authorize the anonymous sharing of my story and assistance received (your name will be removed.)
No, I do not authorize the sharing of my story, name, photo and assistance received

By checking yes, you agree that the Fund may use the information you release at any time and may further approach you about participating in publicity for the Fund or for third parties including but not limited to newspapers, magazines and online media. You may change your publicity status at any time by writing to the Fund. The new status will apply from that point forward, but not to existing produced material. Please note that, by law, we must disclose names of all recipients to the IRS, which makes this information available publicly. By typing your name in the space below, you agree to these conditions.

Applicant Signature *
Signature Date

1. Assistance Requested

Amount:
($1000 maximum for funeral-related requests; $5000 maximum for all other requests)

General purpose:

2. Explain in detail the circumstances leading up to your request for a One Company Grant. Please include how this event(s) was unpredictable, uncontrollable, or both. (Email additional sheets if necessary).

3. Describe other efforts you have made to meet your need AND include documentation of eligibility or ineligibility of any programs for which you have submitted an application or notice (applied for state assistance, working a second job, applied for a bank load, cancelled cable, etc.).

4. Have you called the Employee Assistance Program (EAP) (1-800-854-1445), a free benefit offered to all Benchmark Assisted Living associates Yes   No

Was their help/guidance helpful in your situation? Yes   No

5. If your request is medical-related (working with insurance companies, managing co-pays/payments, resolving insurance claims, etc.) have you called Health Advocate (1-866-695-8622), a benefit offered to associates that participate in medical benefits through Benchmark Assisted Living? Yes   No

Was their help/guidance helpful in your situation? Yes   No

Additional Information

Household Savings Balance $
Do you receive any additional assistance (fuel, energy, etc.)? Yes   No
If yes, please enclose documentation around the program(s).

Number of family members living with you and their relationship to you (not including yourself):
Children Adults over 18
Relationship:

ADDENDUM TO THE COMPANY FUND REQUEST FOR ASSISTANCE

List ALL Sources and Monthly Amounts of your Household Expenses: