Emergency Relief Fund (ERF) Application

Name*
First Last
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Preferred Payment Method*
- Electronic Funds Transfer
- Paper Check
Date*
MM slash DD slash YYYY
Please provide details of lost work due to the Covid-19 Crisis, including date/location/lost wages.
Amount Requested*
How Much Money Are You Requesting from the ERF (up to $500)?
Please enter a number from 0 to 500.
Funds Usage*
How Will These Funds Be Used to Meet Your Immediate Needs?
Additional Information
Is there anything else you would like us to know about your request?
Consent*
I acknowledge that I am requesting emergency funds from Local 1000 Emergency Relief Fund in the form of a grant.

I understand that I may incur taxes on funds I receive from the Local 1000 ERF, and that it is my responsibility to consult my own tax specialist for information about tax status of any money I receive.
I agree to the terms of this application.
Membership Verification*
To apply, you must be a current member in good standing.
I am a Local 1000 Member in Good Standing.
Electronic Signature*
By typing my name in this field I affirm that all information above is true and correct to the best of my knowledge.
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Phone
This field is for validation purposes and should be left unchanged.