Employee Crisis Application

The Employee Crisis Assistance Program was designed by the Sanford Health Foundation to support Sanford and Good Samaritan Society employees facing personal financial hardship due to extraordinary and unexpected circumstances.


A crisis is defined as a significant event(s) or radical change of status in a person's life that creates immediate, unforeseen and substantial financial obligation. A crisis may include the inability to meet basic needs such as food, shelter, and clothing.


Multiple requests for assistance may be considered, as determined by the Employee Crisis Committee. However, employees cannot apply for funds for a specific crisis more than once in a 12-month period.


If you have questions, contact the Employee Service Center at (877) 949-5678.

 

Personal Information

 
 
 
 
Phone
 

Include; house/apartment number, street name/number

 
 
 
 
 

Include; name(s) and age(s)

If you have no dependents type none below.

 

 

Employee Information

 
 
 
mm/dd/yyyy
 
 
 
 
 

 

Previous Fund Use

 
 

 

Additional Resources

 

Examples of public resources; budget heating assistance, food assistance, etc...

 

 

Application Details

 
 
 
 
 
 

 

Personal Assets

 
 

Examples; Child support, current savings, available cash, etc...

 

Spouse/Significant Other

If you do not have a spouse or significant other, please put 0 in weekly net wage and none in other income.

 
 

Examples; Child support, current savings, available cash, etc...

 

 

Amount Owed

Enter the total for each question if applicable. If there is no expense enter 0.

 
 
 

Currently Due Bills

 
 
 
 
 
 
 
 
 
 

Past Due Bills

 
 
 
 
 
 
 
 
 
 

If you requested reimbursement for expenses listed above, please fill out additional information for consideration

 
 
 

 

Information Attestation and Consent

I attest that this information is accurate. I have granted permission for members of the Employee Crisis Committee to review the information I have provided.

 
 

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