To submit this form you will need:
·     2 months of account statements with FULL transaction details (bank statement, bank cards, Chime, Walmart, Wisely, PayActiv, Net Pay, etc.)
·     Last 2 pay stubs
·     All invoices or bills you are requesting to be paid

If this request is related to the death of an immediate family member, the letter of statement, obituary, or funeral expense invoice is needed.

PLEASE READ! The Compassion Fund does not give awards for phone/cable/internet/credit card bills. Failure to provide ALL required information may prolong the application process. All applications will be submitted on Thursday evening for review, and you will be notified of the decision by email on Monday before 5pm CT.

DUE TO INCREASED APPLICANTS IN NEED OF ASSISTANCE CURRENT MAX PAYOUT $750.00. PLEASE NOTE PROCESSING COULD TAKE UP TO TEN DAYS.

Compassion Fund

First Name

Last Name

Have you received an emergency assistance award within the last 12 months? (Required)

Personal Information

Current Mailing Address

City

State

Postal Code

Primary Phone

Marital Status

How many children under 18 are in your household

SHC Community/Facility you are affiliated with.(Must be employed or live within a 20 mile radius)

How Long have you been a part of a Signature HealthCare Community?

If Awarded, Do you want monetary award sent to your facility?

Address to send award to

You will be notified of your Emergency Assistance application status by email. Please verify that you have provided valid contact information. You will only receive communication concerning your application.

Emergency Assistance Information

Total Amount Requested

Total Amount Requested (Max Payout $750.00)

What will the award be used for? Please list the dollar amount per item. (For example, I'm behind on rent. It will cost $700). The Compassion Fund DOES NOT provide for phone, cable, or internet services.

What circumstances have led you to this financial hardship? Please explain in detail what has happened that causes you to be in need now.

Would you like to speak to a chaplain?

Would you like the SHC Prayer Group to pray for you?

What is your prayer request?

What is your preferred method of contact regarding your application?

File Uploads needed

MONTHLY TRANSACTIONS

BANK STATEMENTS/CHECK CARDS/PRE-PAID CARDS

You must submit two recent bank statement, check card, or pre-paid card statements, showing ALL pages. Screen Shots of pages will not suffice and application will not be submitted to committee. Please call your bank for a PDF of statement or retrieve from website.

Check cards: call the customer service number on the back of your card and request a PDF of your transactions records be sent to you.

Last 2 pay stubs (required)

Additional pay stubs (if needed)

1st monthly transactions- (bank statement, prepaid card, check card) required (with full transactions)

2nd monthly transactions- (bank statement, prepaid card, check card) required (with full transactions)
(if needed)

Invoices/bills (required)

Invoices/bills (if needed)

Invoices/bills (if needed)

Invoices/bills (if needed)

Proof of circumstances (required)

Proof of circumstances (if needed)

All other incidental documentation - if request is for Death of Immediate Family Member - Letter of Statement, Obituary, or Funeral Expense Invoice is needed

The Compassion Fund seeks to provide support to employees in times of catastrophic events. A committee will review all requests for assistance. Awards are determined on a case-by-case basis and the amount of your assistance may not equal the amount you have requested. Depending on the situation, you may be asked to provide documentation that supports the details of your emergency.

I acknowledge that by submitting this application I give Signature Foundation permission to use the information I provide for statistical and promotional purposes so long as all personally identifiable information is removed prior to use unless I give express written permission to use my information with personally identifiable information included.

Contact Information