The Ingram Disaster Fund

APPLICATION FOR ASSISTANCE

THE PROGRAM: This Fund helps qualified employees who have experienced natural disaster; life-threatening illness or injury; a death incident; or other certain catastrophic or extreme circumstances beyond their control, and as a result, cannot afford housing, necessary utilities, or other basic living needs.

To qualify for this program and receive assistance you must meet all of the requirements detailed below and submit all required documentation. You can only be approved for assistance once within a 12-month period.

If you have been employed for less than one year, use this form: https://cfmt.formstack.com/forms/ingramemergency

GRANTS: The total grant amount available for assistance varies and is based on each applicant’s documented financial impact, hardship, and demonstrated need. No award amount is guaranteed, as each case is evaluated individually according to the program guidelines. 

Community Foundation staff is available to assist all applicants with this process. If you have questions, send an email to EmergencyGrants@cfmt.org 

Do You Qualify?

To qualify for this program and receive assistance you must meet all of these requirements:
Qualified Incidents*

NOT QUALIFIED: job layoffs, reduced hours or pay, accumulated personal debt, home maintenance, lawful wage garnishment, high utility bills, child support payments, car repairs, taxes, roommate vacancy, or typical separation.

If you have been employed for less than one year, please complete the application found here: https://cfmt.formstack.com/forms/ingramemergency

If you do not meet one of the requirements above, please send an email to EmergencyGrants@cfmt.org to discuss your situation with a member of our team.

You will need these things to complete this application:

  1. Detailed information and exact dates related to your incident
  2. Required documentation related to your incident*
  3. Payment information for the expenses for which you wish to receive assistance (housing costs, utility bills, medical bills)*

If you have questions about any of the above, please send us an email to EmergencyGrants@cfmt.org

*NOTE: You will be able to start your application and submit this form even if you do not have #2 or #3, but you cannot be approved for assistance until we receive all of the requirements listed. If you submit an incomplete application, you will be able to submit the missing information at a later time. 

You may need to submit one or more of the following to show how COVID-19 has impacted you:

  1. Previous payment records to show you were working in normal circumstances (check stubs, pay statements, payroll records)
  2. Your most recent pay record or statement
  3. Information given to you by your employer about closures, sick pay, layoffs, or other information related to COVID-19
  4. Notice of termination or layoff
  5. Medical documentation (if you have been diagnosed with COVID-19)
  6. Information from your childcare provider
  7. Proof of payment for childcare
  8. Any documentation that shows your financial impact

Depending on your situation, these things may not be required. If you have questions about any of the above, please send us an email to EmergencyGrants@cfmt.org.

You will be able to start your application and submit this form even if you do not have documentation, but you cannot be approved for assistance until we receive it. If you submit an incomplete application, you will be able to submit the missing information at a later time. 

Contact and Employment Information

Name
Is it okay for us to contact you through this email address?
Address 1*
Can you currently receive mail at this address?*
Alternate Address
Is it okay for us to leave a message for you at this number?
Is it okay for us to leave a message at this number?
You must have been employed for at least one year to qualify.
We will not share any information with your supervisor without your consent.

COVID-19 Information

Are you applying for help because you or your household have been impacted by COVID-19 / Coronavirus?*

Approval for assistance and the amount that is awarded will depend on demonstrated financial impact. This means you will need to be able to show how COVID-19 has caused your financial distress. If you are being compensated in any way (including use of PTO), you can apply, however, you may not receive assistance immediately. Everyone's situation will be reviewed individually, and we will contact you if we have questions or need more information.

Have you lost income or gone without pay because of the virus?*
When was the last day you worked or plan to work?
What is the estimated date of your last pay? (both past and future dates are okay)
Has another wage-earner that supports your household lost income or been laid off due to the virus. (Including someone paying court-ordered child support)
Have you used PTO/sick time/vacation to make up for lost pay?
Do you anticipate returning to your same position when work is available?
Check all that apply to your situation:*
Submitting recent pay records helps verify your responses and will shorten your processing time. Please submit any records, statements, or pay subs here:
No File Chosen
File uploads may not work on some mobile devices.
Do you have a second file to submit?
Upload second file
No File Chosen
File uploads may not work on some mobile devices.
Do you have a third file to submit?
Upload Third File
No File Chosen
File uploads may not work on some mobile devices.

Describe Your Situation

Type of incident*
(e.g. tornado, flood, type of injury, name of illness, assault, etc.)
Date of the incident*
Enter the date of the incident that is causing your financial difficulty. Must be within the allowed time frame.
Please include only information from the past 60 days if possible.
Your absences will be verified with your employer

Documentation

You will need to submit documentation that reflects the impact of this incident on you and your household.

There are different types of documentation that you can send. Choose the option that is easiest for you.

Natural Disaster: Photographs, insurance reports, FEMA documentation, or other proof of loss is required.

Life-Threatening or Serious Illness or Injury: Completed FMLA paperwork, treatment summary, discharge papers, patient responsibility form, or other medical documentation will be required.

Death Incident: Copy of the death certificate, obituary, or other documentation along with proof of your financial impact will be required.

Catastrophic or Extreme Circumstances: Police, Fire or other official incident report may be required.

If you are not sure what to submit for your application, please contact us and ask for assistance with The Ingram Disaster Fund.


SUBMITTING YOUR DOCUMENTATION

Below you can upload up to 6 files such as photographs or scanned documents. Once you upload your first document, you will be given an option to upload additional items.

You can submit your documentation separately from your application by fax to 615-327-2746 (except photographs), by mail, or by email to EmergencyGrants@cfmt.org with your name in the subject line.

Include your name with anything you send so that it can be matched with your application. Make copies of anything you send to us by mail before you send it to: The Ingram Disaster Fund, 3421 Belmont Blvd, Nashville, TN 37215

NOTE: If you chose to send your required documentation separately, keep in mind that you cannot be approved for assistance without first submitting your supporting documentation.

Are you uploading documentation through this form?
Acknowlegement*

Document #1

Select Your File
No File Chosen
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2MB size limit
Upload a second document?

Document #2

Select Your File
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2MB size limit
Upload a third document?

Document #3

Select Your File
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2MB size limit
Upload a fourth document?

Document #4

Select Your File
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2MB size limit
Upload a fifth document?

Document #5

Select Your File
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2MB size limit
Upload a sixth document?

Document #6

Select Your File
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2MB size limit

Assistance Grants - COVID-19

If you qualify and have already submitted any needed documentation, you will receive notification of approval by email using the address you have supplied above. Please be sure that you have given the address for an account you can access. If additional information is needed to approve your request, you will be contacted by a member of our team.

Because a federal disaster declaration has been made for COVID-19, we are able to provide direct assistance. This means that if you are approved, we will be contacting you to arrange delivery of funds. In almost every case, this will be done by depositing the money directly into your bank account. You will be given access to a secure form to provide your banking information. For those that do not have this option, we will arrange another method. 


Assistance Grants

If the application is approved, payments will be made on your behalf to the vendor(s) you list. All grants are made directly to vendors as bill payments; no assistance funds will be sent directly to you, and no reimbursements can be made.


Grants are only to help pay for limited types of essential living expenses, which are:

  • Rent, mortgage or other housing payments
  • Temporary housing and security deposits for new housing
  • Essential utility bills (electricity, heat, water)
  • Medical expenses incurred within the past 60 days related to the incident and not covered by insurance
  • Minor home repairs needed to maintain home safety and livability

Grants cannot be made to pay for other, non-essential expenses. Do not request payment for these things, such as:

  • Insurance premiums of any kind
  • Cable, phone or internet service
  • Car payments, repairs or car insurance
  • Furniture, appliances, electronics
  • Funeral expenses or grave markers
  • Accumulated financial issues or credit card debt
  • Accidental damages due to negligence
  • Legal fees, legal fines or court costs

INSTRUCTIONS:

For each payment request below, provide the name of the vendor to be paid, the complete mailing address, the account number or identifying information, amount due, and due date. Grant amounts vary, so list the vendors in order of priority. For each vendor, upload the appropriate documentation (bills, lease, mortgage coupon, statement, etc ). If you have difficulty with uploading your bills, you may email them to: EmergencyGrants@cfmt.org.


We cannot make payments for you until we have the complete payment information. Leaving out complete mailing addresses and account numbers will prevent your payments from being made. If you need help or have questions, call 615-321-4939 and ask for help with the Ingram Disaster Fund.

Payment #1

What is the basic need that this payment will cover?
Please review the list of qualified expenses above if checking "Other".

Do not request payment for: Insurance premiums or deductibles; phone, cable, or internet bills; car payments or repairs; funeral or travel expenses; child support payments; legal fees or court fines.

Do not request payment for: phone, mobile phone, internet, or cable TV bills.

Enter the name of your biller as it should appear on the check.
Vendor #1 Mailing Address
Enter the information we need to include to be sure the payment is credited to you.
$
What is the total amount that you owe?
$
Please enter the amount you would like to be paid.
Payment Due Date
Are you going to upload a file for this payment?
Upload your bill, statement, lease, or other documentation for Vendor #1. Size limit: 2M
No File Chosen
File uploads may not work on some mobile devices.
Is there anything else we need to know about this payment?
Do you need to add a second payment?

Payment #2

What is the basic need that this payment will cover?
Please review the list of qualified expenses above if checking "Other".

Do not request payment for: Insurance premiums or deductibles; phone, cable, or internet bills; car payments or repairs; funeral or travel expenses; child support payments; legal fees or court fines.

Do not request payment for: phone, mobile phone, internet, or cable TV bills.

Enter the name of your biller as it should appear on the check.
Vendor #2 Mailing Address
Enter the information we need to include to be sure the payment is credited to you.
$
What is the total amount that you owe?
$
Please enter the amount you would like to be paid.
Payment Due Date
Are you going to upload a file for this payment?
Upload your bill, statement, lease, or other documentation for Vendor #1. Size limit: 2M
No File Chosen
File uploads may not work on some mobile devices.
Is there anything else we need to know about this payment?
Do you need to add a third payment?

Payment #3

What is the basic need that this payment will cover?
Please review the list of qualified expenses above if checking "Other".

Do not request payment for: Insurance premiums or deductibles; phone, cable, or internet bills; car payments or repairs; funeral or travel expenses; child support payments; legal fees or court fines.

Do not request payment for: phone, mobile phone, internet, or cable TV bills.

Enter the name of your biller as it should appear on the check.
Vendor #3 Mailing Address
Enter the information we need to include to be sure the payment is credited to you.
$
What is the total amount that you owe?
$
Please enter the amount you would like to be paid.
Payment Due Date
Are you going to upload a file for this payment?
Upload your bill, statement, lease, or other documentation for Vendor #1. Size limit: 2M
No File Chosen
File uploads may not work on some mobile devices.
Is there anything else we need to know about this payment?

Agreements and Acknowledgements

No employee is entitled to receive a grant, either by their employment, their history of contributions to the Fund or because of any precedent inferred from a previous grant from the Fund. Grants will not be made before an applicant has demonstrated an immediate financial need and provided all required documentation.

This application will be treated in a confidential manner by The Community Foundation of Middle Tennessee; however non-identifying statistical information will be reported to the Company on a periodic basis.

Employees are expected to provide truthful and accurate information. In its due diligence, if The Foundation discovers any information to be untrue, it shall have the right to unilaterally waive its confidentiality and report its findings to the Company. The fiduciary expectations of all employees are paramount and a breach of these standards will be reported to your employer.

Your signature below certifies that the information provided is true and complete, authorizes The Community Foundation to obtain and/or verify all information necessary to process this application, and releases the Company and The Community Foundation of Middle Tennessee from any liability associated with the rejection of or funding of this application. Remember the total grant amount available for assistance varies and is based on each applicant’s documented financial impact, hardship, and demonstrated need. No award amount is guaranteed, as each case is evaluated individually according to the program guidelines In addition, you agree to provide the requested documentation supporting the information provided.

Acknowledgements*
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