Faculty & Staff Emergency Fund Application

Last Name

First Name

Employment Status

FacultyStaffContractual

Employee ID Number (TU employees)

Employment Department

Length of Service

Phone Number

Email Address

Home Address

City/State/Zip

Which of the following categories best describes the reason for your financial emergency?

Significant loss of household income resulting in inability to meet immediate, essential expenses (food, shelter, utilities)Significant unexpected expenses that cannot be delayedUnanticipated expenses related to the care of a dependentEmergency medical, dental, or prescription expenses that must be paid to receive needed careDeath of a family or household member

Please provide a detailed explanation of your financial emergency, including the circumstances that caused your current situation, and how the grant award you are requesting will be used to alleviate the situation.

Example: I need help to make this month’s rental payment. My spouse was laid-off, applied for unemployment benefits but no payment has been received. Rent is $1500/month and we are not able to make a payment, and continue to meet our food expenses. An award of $500 would be used toward rent.

Have you exhausted alternative funding options?

YesNo

Please list other funding options, government programs, community based programs or financial resources you have considered and the result of each? For example, savings account, unemployment benefits, extended payment plan.

Are you in good employment standing with the university or employer? Employees in good standing will have no discipline of any type in the past 12 months.

YesNo

How did you hear about the faculty and staff emergency fund?

Other:

Have you requested emergency funds in the past 12 months?

YesNo

I agree to use any award fund for the requested purpose(s) only.

Agree

To be compliant with accounting procedures, I agree to submit any requested documentation (receipts, statements, etc.) in order to demonstrate why funds are needed or how funds were used or will be used.

Agree

I understand that money received from the TU Faculty & Staff Emergency Fund is taxable income.

Agree

I have read and understand the provisions of the Towson University Faculty and Staff Emergency Fund guidelines. I certify that the information provided on this application is complete and accurate and all supporting documentation that I provide is valid and accurate. I understand that completion of this form is not a guarantee of approval. I understand if I falsify or submit fraudulent information, I will be required to repay the amount awarded, and it will be grounds for disciplinary action.

Agree