COVID-19 Emergency Relief Fund Application

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Date: ______________________________________________

Employee name: _____________________________________

Job title: ___________________________________________

Department: ________________________________________

Each employee is eligible for a maximum of [insert dollar amount] in emergency relief payments for expenses resulting from the COVID-19 national emergency that are not covered by insurance.

Please indicate the expenses incurred due to COVID-19 and provide an explanation of the circumstances that warrant the need for assistance. The following are examples of allowable expenses:

$______ Over-the-counter medications, hand sanitizer and home disinfectant supplies.

$______ Child care or tutoring due to school closings.

$______ Grocery delivery costs.

$______ Incurred expenses due to work-from-home arrangements such as setting up a
                home office, increased utilities and higher Internet costs.

$______ Increased commuting costs, such as taking a taxi instead of using public mass
                 transit.

$______ Unreimbursed medical expenses.

$______ Critical care and funeral expenses.

$______ Other: _____________________________________________________

Ineligible expenses include lost wages and normal living expenses not impacted by COVID-19 such as mortgage, rent and food. Nonessential and luxury or decorative items and services are also excluded.

Explanation of need for assistance:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Employee signature: _________________________________ Date: ___________________

Submit this completed form to the human resources department.

For internal use:

Date received:

Approved:  Yes/No

If approved, date submitted to accounts payable:

Reviewer name:

Signature: