GRANT APPLICATION FORM
 
The Employee Relief Fund (ERF) is intended to provide immediate temporary assistance to International Paper employees for basic necessities (food, clothing and shelter) resulting from a natural disaster (e.g., flood, earthquake, hurricane) or a personal emergency (e.g., house fire, flooding).   Funds will be provided based on the guidelines established.  The ERF is not meant as a replacement for insurance, and does not cover medical issues, home repairs or lost wages. 

Please complete this application and submit it to the ERF via the Submit Application button below.  If you have any trouble submitting the application on-line, please print the application out and provide it to your HR manager or email it to amy.grow@ipaper.com.  


Date:


Name:


Applicant's Email Address:


Applicant's Cell Phone Number:


Job Title:


Employee Number (if known):


IP Facility:


Applicant’s Human Resources Manager:


Current Contact information:


Employee’s number of dependents in household:


Employee’s home address:


ERF Funds will normally be sent to the employee’s facility; however, if the employee prefers that funds be sent to another address, please provide here:

Have you experienced a natural disaster (e.g., flood, earthquake, hurricane) or a personal emergency (e.g., fire, flooding):
YES    NO

If Yes: Date of incident?


If Yes: Explain the incident:


Are you able to live in your home?
YES    NO 

When do you anticipate you will be able to return to your home?


If unable to live in your home, where are you staying? 


Number of days unable to live in home? 


Estimated cost for shelter:  

Have you lost clothing?
YES    NO
If Yes, estimated cost for clothing:
$

Have you lost food?
 YES    NO
If Yes, estimated cost for food:
$

Have you received assistance from insurance or an outside agency? (e.g., Red Cross, FEMA, United Way)
YES   NO    
If Yes, explain:


Additional Comments:



 I hereby certify that I have incurred the losses set forth above as a result of a natural disaster or personal emergency; and that these expenses are not eligible for payment or reimbursement by insurance or any other source.

Please type your First and Last Name:
First Name  
Last Name 

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document.