The SSR Disaster Relief Cares 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.

GRANTS: The maximum grant amount available for assistance is $7,500. The maximum award is not guaranteed, and in many cases, a lesser amount will be awarded. All payments are made directly to vendors as bill payments. No assistance funds will be sent directly to applicants, and applicants will not be reimbursed.

Community Foundation staff is available to assist all applicants with this process. If you have questions, send an email to EmergencyGrants@cfmt.org for assistance with The SSR Disaster Relief Fund.

Do You Qualify?

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

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

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 and ask for help with The SSR Disaster Relief Fund.

*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. 

Contact and Employment Information

Is it okay for us to contact you through this email address?*
You will automatically recieve a confirmation email when you submit your application.
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?

Housing

Describe your housing arrangement*
This information helps us supply housing assistance for you
Is your rental payment made to:

Describe Your Situation

Type of incident*

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

Catastrophic or Extreme Circumstances - Have you experienced any of the following?
(e.g. tornado, flood, type of injury, name of illness, domestic abuse, etc.)
Date of the incident*
Enter the date of the incident that is causing your financial difficulty. Must be within the program time limit.
How has this loss caused a financial impact for you?
Damage to your home or essential belongings - check all that apply
The Fund cannot pay to repair other property such as fencing, carports, garages, or storage buildings, and cannot pay to replace non-essential items, such as electronics.
What kind of documentation or paperwork do you have that shows your losses?
Have you been displaced from your home?
Where have you stayed away from your home?
Do no include hotel or temporary housing costs
How has this medical situation affected you and your family?
Has the disaster caused you to take UNPAID days away from work?
Do not include days where sick time, vacation, or other PTO was or will be used.
Check all medical services received as a result
What kind of medical documentation or paperwork do you have?
Do you expect insurance of any kind to help cover your losses?*
Type of Insurance?
Housing costs, basic utilities, medical costs, food, clothing
Please include only information from the past 60 days if possible.

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 SSR Disaster Relief 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 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 SSR Disaster Relief Fund, 3451 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
File uploads may not work on some mobile devices.
2MB size limit
Upload a second document?

Document #2

Select Your File
No File Chosen
File uploads may not work on some mobile devices.
2MB size limit
Upload a third document?

Document #3

Select Your File
No File Chosen
File uploads may not work on some mobile devices.
2MB size limit
Upload a fourth document?

Document #4

Select Your File
No File Chosen
File uploads may not work on some mobile devices.
2MB size limit
Upload a fifth document?

Document #5

Select Your File
No File Chosen
File uploads may not work on some mobile devices.
2MB size limit
Upload a sixth document?

Document #6

Select Your File
No File Chosen
File uploads may not work on some mobile devices.
2MB size limit

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. If you receive any assistance, these funds will not be included in any calculation of your gross income for federal or state income tax purposes.


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
  • Funeral, burial or cremation costs
  • 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
  • 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. Although the maximum grant amount is $7,500, smaller sums are often awarded, 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 SSR Disaster Relief 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; 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; 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; 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. If you receive any assistance, these funds will not be included in any calculation of your gross income for federal income tax purposes. 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*
Use your mouse or finger to draw your signature above
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