Pillars Provides

CLICK HERE TO VIEW ELIGIBILITY REQUIREMENTS

CONTACT INFORMATION

Name*

First Last

Hometown*

City and State

Email*

APPLY FOR ASSOCIATE HARDSHIP FUND GRANT

TO VIEW ELIGIBILITY REQUIREMENTS

Phone of individual applying for the associate hardship grant fund*

Department and business location*

Position*

Tenure with Upstream/Upstream affiliated brands*

Note: must be at least six months

Is this hardship application in direct response to change in employment status?*

Yes
No

Were you furloughed in the past year?*

Yes
No

Did you have to quarantine or take time off for COVID related issues?*

Yes
No

If Yes, did you use PTO to cover your time off?*

Yes
No

The hardship involves and affects me and/or my immediate family (spouse, children, step-children, siblings, parents, and/or grandchildren who are financially dependent upon me.*

Yes
No

If yes, please describe*

Please describe how the incident prevents you from meeting your financial obligations.*

Please list all the efforts you have taken to alleviate this hardship including other sources of financial aid or social aid:*

Name of immediate supervisor*

First Last

Immediate supervisor's phone

Immediate supervisor's email

Name of RVP

First Last

REQUIRED DOCUMENTS

List of bills / utilities needing assistance*

Company owed	Address of company	Essential need provided	Amount Owed	Date Due	Name of Applicant

Examples of Essential needs are: rent, electric, medical, transportation, childcare, etc. Press the + sign to add additional bills / utilities

UPLOAD DOCUMENTS HERE

Upload Copies of current bills/invoices for which grant is requested.
Other documents to substantiate the current amounts owed as listed above If requesting reimbursements for previously purchased items, to help you meet basic standard of living, receipt of payment for those necessities are required.
Dates of purchase must be legible.

What is the format of your documentation (check all that applies)*

PDF
JPG
PNG

Upload current bills/invoices (PDF FILE FORMAT)*

Accepted file types: pdf, Max. file size: 300 MB.

Upload current bills/invoices (PDF FILE FORMAT)

Accepted file types: pdf, Max. file size: 300 MB.

Upload current bills/invoices (PDF FILE FORMAT)

Accepted file types: pdf, Max. file size: 300 MB.

Upload current bills/invoices (JPG OR PNG FORMAT)*

Accepted file types: jpg, jpeg, png, gif.

Upload current bills/invoices (JPG OR PNG FORMAT)

Accepted file types: jpg, jpeg, png, gif.

Upload current bills/invoices (JPG OR PNG FORMAT)

Accepted file types: jpg, jpeg, png, gif.

ASSOCIATE CERTIFICATION STATEMENT

Due to an incident outside of my control, I am in need of financial support to meet my immediate obligations. By signing this application, I certify that all of the information contained in this application is true and correct. I authorize the Benevolent Fund for Associate Hardship Advisory Committee to obtain and/or verify all information necessary to process this application. Additionally, I understand that no associate is automatically entitled to receive a grant, either by their employment or because of any precedent inferred from a previously approved grant. I understand grants will not be made before an associate has demonstrated an immediate need.

Associate Signature*

Type your Legal Name

Date*

Comments

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Pillars Provides