Employee Relief Application ERF Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work Phone(Required)Home or Cell Phone(Required)Work Email(Required) Alternate Email Job Title(Required)Department(Required)Supervisor's Name(Required) First Last Please select:(Required)Full-TimePart-TimePRNHow long have you been employed at SRMH(Required)Please enter a number from 1 to 50.Why do you need financial assistance?(Required)Provide details and timeline of the situation that has brought you to need assistance. What problems are you experiencing?(Required)If you have experienced a medical emergency, please provide details and dates related to surgeries etc.Why are you unable to meet your financial obligations?(Required)Please indicate how many hours you have available:(Required)PTOSick Add RemoveAre you currently working?(Required) Yes No Are you off work due to illness or injury?(Required) Yes No Have you applied, or will you be applying for Short Term Disability?(Required) Yes No Are there others you can ask for support or assistance?(Required) Yes No What is your annual household income (please include all household members contributing to the total income)?(Required)How many people are in your household?(Required)How many dependents are in your household?(Required)What are the ages of each of the dependents?(Required) Add RemoveWhat is the specific amount of money you’re requesting?(Required)Please list what you will you be using the money for?(Required) Add RemoveALICE InformationApplication approval is determined, in part, by utilizing a nationwide income eligibility tool. The information below is required to complete your application. If you do not have this documentation available, please select "Save & Continue" below. This will allow you to return to the application to complete the file uploads when you are ready. Please list all monthly household bills below: Scanned copies of each bill must be provided and accompany this application (required)(Required)Bill Type (ex. mortgage)Bill Due DateBill AmountOutstanding Balance (if applicable) Add RemoveFile(Required) Drop files here or Select files Max. file size: 10 MB. As a regular part of our program, we contact your supervisor to verify work history and timeline. By submitting this application, you agree to permit this exchange of information. The Committee would also like to offer you support through the Employee Assistance Program. If you need help or want to schedule an appointment, please call Sentara EAP at 1-800-899-8174If this form is submitted on behalf of another employee, have you received permission from that employee to submit his/her name?(Required) Yes No
