hardship by fanzhongqing

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									       WACHOVIA                                                   WE Care
                                                                  Wachovia Employees Care Fund


Application for Assistance – Emergency Hardship
The WE Care Fund is administered by Foundation For The Carolinas, a non-profit organization
that serves donors, communities and a broad range of charitable purposes. A Review Committee
of non-Wachovia members reviews applications and makes grants monthly. Submitting a request
for funds through WE Care and completion of this application is completely voluntary. The
information supplied will be kept confidential and may be reviewed only by individuals involved
in administering the WE Care Fund. Decisions regarding applications will be communicated in
writing by US mail. Please read carefully.

WE Care Funds are granted to eligible employees suffering from severe financial hardship
resulting from a sudden, overwhelming, unexpected event beyond their control. WE Care funds
are intended for use by those who do not have other resources to help themselves. Certain
charitable income guidelines apply.

WE Care Requests up to $10,000 may be granted for:
  • Basic living expenses not covered by insurance or help from other organizations including:
     housing, home repair (for primary residence only), food, clothing, transportation.
     WE Care provides one-time assistance to help employees get back on their feet with basic necessities.
     It does not help repair or replace everything lost or damaged in a catastrophe.
  • Extraordinary medical expenses of a short-term nature not covered by insurance

WE Care Requests must be for expenses that are:
  • Incurred on or after 1/1/2003 or the employee’s hire date, whichever is later,
  • Short-term in nature,
  • Able to be resolved with a single grant.

Requests that will NOT be granted include:
Lost compensation due to missed time from work; items covered by an individual’s insurance;
routine, on-going or long-term medical expenses; elective medical procedures; insurance
premiums; credit card debt or pay day loans; employee benefits during waiting periods for
coverage; legal fees; and expenses associated with divorce settlements and child custody cases.

Send completed Application for Assistance and supporting documents to:
The WE Care Fund, Foundation For The Carolinas, 217 S. Tryon Street, Charlotte, NC 28202. Fax:
704 973-4936. E-mail: WECare@fftc.org.

If you have questions, contact the WE Care Fund Program Coordinator toll-free at 1-877-569-CARE
(2273) or in Charlotte at (704) 973-4536.
Employee Information
All three statements below must be true to apply for WE Care assistance. Do not complete the
rest of the application if all three statements cannot be checked.
_____ I am an active employee of Wachovia or an employee on leave with pay, including Short-
        Term Disability (STD) and Paid Time Off (PTO).
_____ I am NOT a contract or temporary employee (or First Place employee) or a retiree.
_____ I am NOT on unpaid leave or Long Term Disability (LTD).

Last Name:                           First Name:                           Middle Initial:
Employee ID #:___                                 __________________________________________
Hire Date:                                  # Hours Scheduled to Work per Week: _____________
Job Title:                                  Department:
Work Address:
City:                                       STATE:                         Zip:
Work Phone:                                        Work Email:
Manager’s Last Name:                        First Name:
Manager’s Work Phone:                       Manager’s Email:
Employee’s Home Address:
City:                                       STATE:                         Zip:
If, because of the catastrophe, you cannot receive mail at your home address please give another
mailing address for us to use: __________________________________________________________

Home Telephone:                         Cell Phone: _____________________________________
Home Email:                                   _________________________________________
Marital Status:                         # of dependents claimed on taxes:
Dependents’ Ages/Relationship to Employee:
Have you applied before for WE Care assistance?     __ If YES, date applied (Mo/Yr):

Hardship Situation Beyond Your Control
Catastrophes are personal/family (including domestic partner), sudden, unexpected, overwhelming
events and include, but are not limited to illness, death, accident, violent crime, or other personal
events of an unexpected and ruinous nature.
Catastrophic event and dates                         Financial hardships caused by event,
                                                     $ amounts and dates




                                                                                                    1
Financial Information
   A. Your annual gross (before deductions) salary or wages        $                Per year
      Typical take home pay amount each paycheck                   $                Per check
   B. Your spouse/partner’s annual gross salary or wages           $                Per year
      Typical take home pay amount each paycheck                   $                Per check
   C. Child support income                                         $                Per year
   D. Social Security income                                       $                Per year
   E. Disability income                                            $                Per year
   F. Unemployment income                                          $                Per year
   G. Alimony                                                      $                Per year
   H. Other income (please describe)                               $                Per year
Please attach copies of most recent pay stubs for each wage earner. (For the Wachovia
employee, please print your most recent pay stub detail from HR ONLINE and attach.)

If you or your spouse/domestic partner are currently or have been on Short Term Disability
(STD) related to this catastrophe, please complete the following:
Date STD started (Mo/Day/Yr): ______________________________________________________
Take home pay stub amount at 100%: $ ________________________________________________
Date STD pay went to 60% (Mo/Day/Yr): ______________________________________________
Take home pay stub amount at 60%: $ _________________________________________________
Date STD ended: ____________________ OR Date STD is expected to end: ________________

Please list all current monthly expenses and debts (rent/mortgage; utilities: electricity, natural
gas, oil, water , phones, cable, internet ; auto loans; insurance premiums; credit cards; medical
bills; other loans; food; gas; childcare; etc.)
   Name of creditor Monthly            Past due Balance         Due      Purpose of payment
                        payment $ amount $ due $                date     (Example: Rent)




                                                                                                     2
WE Care Grant Amount Requested (REQUIRED for consideration): $
 Please list in itemized detail how the funds will be used. Processing of application will be
 delayed if request is not itemized.
  Amount requested        To be used for




Please attach copies of repair or replacement estimates, past due bills, foreclosure/eviction
notices, medical EOB’s, etc. as applicable.

Medical Information
If request is related to a medical condition, please attach written diagnosis and prognosis from
the physician describing the condition.
If requesting reimbursement for out-of-pocket medical expenses not covered by insurance,
attach copies (keep originals for your records) of your Explanation of Benefits (EOB) forms. Your
medical insurance company sends you these forms when they pay medical providers on your
behalf. Do not send copies of doctor or hospital bills.


Recovery Plan
You must show that you have done everything possible to help yourself before turning to WE
Care. And you must show a recovery plan in which you are able to live on your income going
forward. Please spell out the full name of organizations, no abbreviations.
   Action Taken                      Results and $ Amounts                  Date
   (Check those that apply)
   ___ Homeowner’s Insurance
   ___ Renter’s Insurance
   ___ Auto Insurance
   ___ Medical Insurance
   ___ Life Insurance
   Red Cross
   Federal Emergency Mgmt
   (FEMA), if applicable
   Your religious community
   Family members
   Loan Program: Wachovia
   Employee Financial Services
   Loan Program
   Employee Benefits
   Other
                                                                                                    3
   Recovery Plan Action               Recovery Plan Results
   Example:




Authorization
I have done everything possible to help myself before applying for this grant. I certify that the information
provided in this grant application is true and correct as of the date set forth below. I authorize Wachovia
Corporation Employee Benefits and Payroll to release information to WE Care regarding this application.
My signature acknowledges and permits Foundation For The Carolinas to verify all information. Any
intentional misrepresentation of information contained in this application will result in forfeiting this grant
application now and in the future.
Signature Required:                                                                     Date:

Please remember to attach copies of pay stubs, repair or replacement estimates, past due bills,
foreclosure/eviction notices, medical EOB’s, etc. as applicable.




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