Ken LaChance Colleague Emergency Fund Application

The purpose of the Ken LaChance Colleague Emergency Fund is to provide limited financial assistance to eligible colleagues who are experiencing economic hardship due to certain current emergency situations. Situations do not need to have occurred during business hours or have any relation to work. Situations should be temporary or short-term in nature and not chronic. Colleagues will be referred to an appropriate source (i.e., Convergint EAP, community agency, Consumer Credit Counseling Service, etc.) if their circumstances do not apply to this program. Examples of economic hardship which can result in a personal or family crisis, and which are considered as qualified under this program, may include a non-routine medical expense, serious illness or injury, fire / flood / natural disaster, violent crime, death of a colleague or eligible dependent, domestic violence, military deployment, unemployment issues with family, housing, extraordinary expenses not covered by insurance, or other undue hardships not caused by the colleague. Before submitting an application, please review the Fund Description and FAQs on our website to confirm eligibility: https://kenlachancefund.com/

My disability prevents me from completing this application.

Ken LaChance Colleague Emergency Fund is committed to providing reasonable accommodations for individuals with disabilities.

My disability prevents me from completing this application.

Emergency Situation Eligibility

I certify I meet the following eligibility criteria to receive a grant under the guidelines of the Ken LaChance Colleague Emergency Fund.

A qualified application MUST meet these criteria

The applicant has continuously worked at Convergint for three (3) months or longer.

The applicant has not received a grant in the past thirty six (36) months.

This is a current emergency situation (last 120 days).

This emergency situation has not been caused by the applicant.

This emergency situation causes the applicant an unforeseeable financial hardship.

Date of the current emergency situation described below (last 120 days)

This is the triggering date that caused the financial hardship to occur. If the financial hardship date is different than the emergency event date, please include details of the timeline in the other comments (question #7).

mm/dd/yyyy

Name the current emergency situation that caused this economic hardship on the date provided above

Examples may include a non-routine medical expense, serious illness or injury, fire / flood / natural disaster, violent crime, death of a colleague or eligible dependent, domestic violence, military deployment, unemployment issues with family, housing, extraordinary expenses not covered by insurance, or other undue hardships not caused by the colleague.

NOTE: Detail should be provided below in Question 1

Eligibility criteria notice:

Applicant MUST meet all the criteria outlined in order to be eligible to receive a grant under the guidelines of the Ken LaChance Colleague Emergency Fund. If you can not check all the boxes above, this application will still be submitted for review.

Applicant Information

If you are a U.S. or Canadian colleague, you may use the below grant application. The only scenario where it would be acceptable for an application to be submitted on someone else’s behalf is if that person is disabled in such a manner as to not be able to complete the application. If you believe that a fellow colleague might qualify for assistance, please direct them to contact the Program Administrator (cefrequest@convergint.com), their local business leader, or review the information available on our website www.kenlachancefund.com.

I am applying on behalf of:

Self

Surviving dependent or family of eligible colleague

Another Colleague

Name of eligible colleague

Note, for purposes of this application, applicant refers to the eligible colleague for which the grant is being requested. If this form is submitted by someone other than the colleague, please enter information on behalf of the eligible colleague. Please provide details in your responses below indicating why the applicant is unable to submit this application.

Hire Date

Enter most recent hire date or start date of temporary employment.

mm/dd/yyyy

Primary phone

Phone

Secondary phone

Phone

Applicant company email

Please enter the applicant's company email or previous email. If you are an active colleague, this email address will by used to communicate application status.

Alternate email address (optional)

Please enter an alternate email. Communications will also be sent to this address regarding the application status, if provided.

Applicant is not receiving company email at this time, please send correspondence to alternate email address only.

Street address

City/Municipality

State/Province

Zip

Country

Canada

United States

Grant request information

Please answer the following questions completely.

All information given will be confidential. Financial disclosure is required (if additional space is needed, use a blank sheet and attach to the application).

Select one:

Documentation which clearly identifies the expense associated with the request shall accompany the application.

Please be aware that the Colleague Emergency Fund Committee may request additional information to verify financial need and access to other financial resources prior to grant approval.

I can provide copies of documentation for this emergency situation

At the time of the application, I CANNOT provide copies of documentation for this emergency situation

Grant amount requested

The maximum amount allowed may be up to $5,000.00. Under no circumstance will the financial assistance exceed the cost of the expense being considered. Any approved amount will be deducted from the Fund. Eligible colleagues can apply once within a 36 month period. This is a tax exempt grant and is not considered taxable income subject to IRS or Revenue Canada taxation. Approval of an application can be either partially or fully funded depending on the situation. Colleagues are not required to pay back a grant as this is not a loan; however, they are encouraged to do so, since this will help replenish the fund for future requests. If the grant is paid back, it is considered a charitable contribution and may be deductible for tax purposes (U.S. only or Canadian citizens with U.S. source income and then the exemption is limited to 75% of that amount).

Details for the selection committee to review your application

Please note, your identity and the information contained in your application is kept strictly confidential. The selection committee will not receive any detail that may identify you, therefore, it is important to provide complete answers to the questions below to help them make an informed decision.

1. Provide details explaining the emergency situation that has caused the financial hardship, including when you became aware of the situation, and how long you expect the situation to last.

2. How will the grant be spent? Provide a detailed description of the specific expense(s) this grant would be used for and include any available documentation.

3. Describe your existing assets or available resources to meet this emergency; cash, checking and savings accounts, investments, loans, and other sources of income.

4. Describe the alternatives available to you if the grant is not awarded (i.e., 401k loan or hardship withdrawal, RRSP withdrawal, bank loan, etc.)?

5. Will any of these expenses be covered by insurance? Provide details of insurance coverage and deductibles available to cover this emergency situation, and the date you expect to receive insurance.

6. Have you ever applied for a grant from this fund before? If so, when and what was the result?

7. Other comments or information that would be helpful in reviewing this grant application?

I certify that the information provided in this grant application is true and correct to the best of my knowledge. Any intentional misrepresentation of information contained in this application will result in forfeiting this and any future grant application. I authorize Ken LaChance Fund, Inc. and the Program Administrator to verify my employment earnings records, bank accounts and/or any other assets needed to process my grant application. I understand that any grant I receive from this program is considered a charitable contribution and is not considered taxable income subject to IRS or Revenue Canada taxation.

Your typed name will serve as your eSignature

By submitting this application online, you agree to electronic signature. If you prefer, you may print and sign the completed document.

Today's date

mm/dd/yyyy

An email confirmation will be sent to the email address(es) you provided.

If you prefer, you can email a printed, completed application to CEFrequest@convergint.com. Alternately, you may mail a completed application to: CEF Program Administrator One Commerce Drive Schaumburg, IL 60173 *Allow longer handling time for mailing.

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