If you learned about us from personal referral, who referred you? If you found us through a Google search, what were your search terms? If you learned about us while at a Jack's restaurant, was it an employee who said something or did you see signage of some kind? If you found a link to us on another web page, what web page?
Section I: Applicant Information
The applicant is the individual who is experiencing the hardship/ in need of assistance.
Please enter your six digit employee ID number
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Please upload a copy of your government issued photo ID. (E.g. driver's license, voter ID, state ID, passport)
For example - unemployment benefits, severance pay, short-term disability, SSI/SSDI benefits, retirement income
NOW HIRING - Come join the Jack's family! We are hiring for both management and crew team positions at most restaurant locations. Learn more and apply online at WorkAtJacks.com
You may list more than one potential employer or pending job application by clicking the "+" at the end of the row.
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If you learned about us from personal referral, who referred you? If you found us through a Google search, what were your search terms? If you learned about us while at a Jack's restaurant, was it an employee who said something or did you see signage of some kind? If you found a link to us on another web page, what web page? If you learned about during the hiring/training process, when specifically?
If you live alone, please enter "1"
List yourself then click the "+" at the end of the row to add a row for each person in your household.
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Example: Myself, 30; Bob, 20, my roommate; Joe, 12, my son; Chris, 8, Roommate's son
For example, do you receive food stamps, child support, or disability benefits? Does your spouse, roommate or child work and help pay the household bills?
For example: If you receive $250/month in food stamps and your son contributes $200/month from his paycheck, write "Food Stamps=$250; Son=$200"
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Please explain your understanding as to why you did not receive the economic stimulus payment in 2020.
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On Dec. 29, 2020, the IRS began issuing a second round of Economic Impact Payments as part of the Coronavirus Response and Relief Supplemental Appropriations Act of 2021. Direct deposits began on 12/29/20 and paper checks/debit were scheduled to begin distribution on 12/30/20. Have you received this most recent stimulus payment yet?
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Please be as specific as possible. For example, "I received $1200. $400 went toward my electric bill and the remainder went toward my past-due rent."
Section II: Request for Financial Assistance
(Must be Completed)
How, specifically, has the COVID Pandemic caused your current financial hardship?
E.g. Copy of Covid test results, Doctor's Excuse from school/ work listing COVID infection, date/time stamped photo of at home test
What was the hardship that caused you to fall behind on your rent/mortgage?
Being underemployed (not earning enough to cover your living expenses) or being unemployed are not considered hardships under our funding guidelines UNLESS you can verify that the situation is the direct result of one of our qualifying hardship categories.
You may upload copies of these bills/statements under "Supporting Documents" below. If you do not have them available for upload at this time, we will contact you with instructions on how to submit them separate from your application.
Please provide name and contact information for two motels/hotels that will work well for you. Total nightly rate (including taxes and fees) should be $75 or less.
If you are seeking assistance with a past due utility bill or a medical bill, please provide the last four digits of the social security number of the account holder
- Please note: Grants are NOT awarded to help with:
- Paying off credit cards, pay-day loans, or title loans
- Fees or Tuition for school
- Car repairs
- Making car payments
- Down payments on a vehicle
- Fuel
- Cable, internet, cell phone and other subscriptions
- Utility companies have, for the time being, suspended disconnections. Most evictions and foreclosures have also been put on hold. As a result, grants for assistance with past due utilities, rent, and mortgage have been temporarily restricted to allow us to focus our response on situations where individuals’ welfare and safety are in immediate jeopardy. We understand there may be other mitigating circumstances and will continue to review every application on a case-by-case basis.
USD ($)
The Fund pays assistance directly to creditor, not to individual applicants. For example, if you are seeking assistance with funeral expenses, the Fund would pay directly to the funeral home.
What incident(s) contributed directly, and indirectly, to the applicant's financial hardship?
For example: If you took time off, how many days? Have you returned to work? If your had to reduce your hours, by how much and when do you expect to be able to resume your normal work load?
Supporting Documents
You may submit copies/photos in the "Fire - File Upload" section below.
Please upload verification of the fire. You may upload up to 3 files.
Secuirty Deposit and Rent
Please submit something in writing from the landlord detailing
- Address of property
- Terms of the lease
- Monthly rent $
- Security deposit $
- Total $ due to move-in
- Move-in dated
- To whom/where to make payment. If you will be renting from an independent landlord, we will also need a copy of his/her photo ID.
Utility Deposit
If you need assistance with deposit to get electricity and/or water turned on in your new residence, please submit something in writing from the utility company detailing the charges.
Examples: Draft of new lease, utility company deposit/new service information
Emergency/ Short-term Housing
Please submit something from the motel/hotel in writing stating weekly rate plus taxes and fees and contact information for the general manager, including email address and fax number. If your request is approved, we will work directly with the property to arrange for "third party" payment for your room.
You may submit copies of these in the "Natural Disaster - File Upload" section below or email separately.
Please submit copies/photos of the items you selected above.
You may submit copies of these in the "Past Due Rent/Mortgage - File Upload" section below.
Please submit copies/photos of the items you selected above.
You may submit copies of these in the "Death/Funeral - File Upload" section below or email separately.
Please submit copies/photos of the items you selected above.
You may submit copies of these in the "Illness-File Upload" section below or email separately.
Please submit copies/photos of the items you selected above.
You may submit copies of these in the "Accident/Crime - File Upload" section below.
Please submit copies/photos of the items you selected above.
Please upload copies/photos of the entire past due utility bill. We need to see the entire page. Electric, Water, Natural Gas, Trash are eligible for consideration. Phone, Cable, Internet are not eligible for consideration.
Most medical providers will work with you on a payment arrangement. We will give consideration to helping pay for medically necessary treatment/procedures that must be paid PRIOR to receiving treatment OR are past due and in danger of being referred to collections. Please upload the entire page of the bill, invoice or treatment estimate/plan.
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Monthly Budget
Once your current hardship is resolved, what will your monthly budget look like?
Using one of these templates, please complete and submit your monthly budget.
To submit your budget you may:
Please submit copies/photos of your monthly household budget and verification of any income or benefits listed on the budget (paystubs, W-2, benefit award letter, 1099, etc.)
Every applicant must submit:
- Driver's license or other government issued photo ID
- Supporting documentation verifying hardship, requested assistance, and payable entities
- Copies of the bills you are seeking assistance to pay
These images/files may be uploaded below under the "File Upload" section. If you can not upload them at this time, we will contact you via email or text with instructions on how to submit them separate from this application.
Section III: Other Assistance
(Must be Completed)
(examples include other charitable or religious organizations, insurance, government aid programs or other federal, state or local assistance)
US $
Section IV: Prior Fund Assistance
(Must be Completed)
Section V: Applicant Certification
(Must be Completed)
I certify that to my knowledge I am in compliance with all laws, statutes and regulations restricting U.S. persons from dealing with any individuals, entities or groups who are subject to economic sanctions imposed by the U.S., such as countries subject to embargoes or groups of individuals, such as terrorists and narcotics traffickers.
I consent to the processing of my personal data contained in this Application for verification purposes and the potential disbursement of a grant from the Jack’s Family Fund. I further consent to the transfer of the contents of this Application to the Fund located in Birmingham, Alabama, USA, the Jack’s Family Fund Administrator, the Jack’s Family Fund Board of Directors or Allocation Committee Members.
I further certify to the Fund that the information contained in this Application is true and correct.
By accepting a gift from the Fund, I agree to provide copies of the following materials if requested by the Foundation: receipts demonstrating the emergency hardship, my expenditure, and documentation illustrating my relationship to the Applicant, if I am submitting this application on behalf of someone else.
First and Last Name of person completing the application.
