Apply for Aid

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Application Form

 

Please read the following important information carefully before completing this form:

You must certify and demonstrate that you have an immediate and heavy financial need that necessitates assistance.

You must certify that you have no other source of funds to pay for this financial need, including but not limited to, any insurance funds, 401k plans or any other retirement plans and assistance from family/friends.

It is recommended that you be a current Avantive Solutions employee OR have a sponsor who is an Avantive Solutions employee. If you have a sponsor, please provide a written recommendation.

You must not have had more than one grant from Avantive Solutions within a calendar year (Jan-Dec).
If you are requesting over $1,000, the grant will be escalated to the Avantive Solutions Executive Board for review and approval.

REASON FOR HARDSHIP REQUEST

I hereby request assistance in accordance with the Avantive Solutions Application Guidelines. I am an Avantive Solutions employee or have attached a written recommendation from my Avantive Solutions sponsor and the appropriate documentation as proof for my assistance request.

Please explain your situation and specify what the funds will be used for (if it is an immediate family member who is ill or injured, please note the relationship of the person to you):

Please upload supporting documents:

Max file size: 2MB. Files must be one of the following formats: DOC, PDF, JPEG, JPG, PNG.

Resolve Issue

Please attach documentation to support your request:

Max file size: Files must be one of the following formats: DOC|TXT|PDF|JPEG|PNG.

Have you received an Avantive Solutions grant before?

YesNo

Please note that Avantive Solutions guidelines state that more than one grant in any given calendar year may not be granted.

Amount Requested

Payee Contact Information

*Please note if approved, Avantive Solutions will only pay third party vendors directly for individual grants and not the individual grantees themselves unless approved by the Avantive Solutions Executive Board.

*By checking the following box, you agree to grant Avantive Solutions access to privileged personal information related to this application; including, but not limited to bank records, medical records, etc. You therefore permit Avantive Solutions to contact and communicate with third party vendors and other persons/organizations to discuss and attain information related to your hardship claim. This information will be used ONLY in relation to your application and will otherwise be held in full confidentiality by Avantive Solutions staff and chapter board members.

Check here if you accept these terms. (required)

PARTICIPANT CERTIFICATION, ACKNOWLEDGMENT AND AGREEMENT

I certify that the information and supporting documentation that I have provided is complete and accurate. I have read and agree to the Avantive Solutions Application for Assistance Guidelines. I certify that if funds are requested, the amount of distribution requested above is not in excess of the amount necessary to satisfy the financial need described above, and that I have previously obtained all distributions and non-taxable loans available to me. I have exhausted all of my resources. I agree to provide the Avantive Solutions Administrator with evidence of the existence of the financial need and the amount necessary and other documentation requested to satisfy such need upon request.

I understand that the Avantive Solutions Chapter Board (if any) and/or the Avantive Solutions Executive Board will review my application and will determine whether I qualify for the amount requested. I understand that failure to provide complete and accurate information may disqualify me from receiving any funding.

Applicant Signature

By typing in your full name above, you are digitally signing this form.

Date

 

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