Application Form













    Please read the following important information carefully before completing this form:

    • You must certify and demonstrate that you have an immediate and heavy financial need that necessitates assistance.
    • You must certify that you have no other source of funds to pay for this financial need, including but not limited to, any insurance funds, 401k plans or any other retirement plans and assistance from family/friends.
    • It is recommended that you be a current Alorica employee OR have a sponsor who is an Alorica employee. If you have a sponsor, please provide a written recommendation.
    • You must not have had more than one grant from MLBA within a calendar year (Jan-Dec).
    • If you are requesting over $1,000, the grant will be escalated to the MLBA Executive Board for review and approval.


    REASON FOR HARDSHIP REQUEST

    I hereby request assistance in accordance with the MLBA Application for Assistance Guidelines. I am an Alorica employee or have attached a written recommendation from my Alorica sponsor and the appropriate documentation as proof for my assistance request.

    Please explain your situation and specify what the funds will be used for (if it is an immediate family member who is ill or injured, please note the relationship of the person to you):


    Please upload supporting documents:

    Supports the following uploads DOC,TXT,PDF,JPEG,PNG


    Please attach documentation to support your request. The list below provides information on appropriate documentation for each potential case:

    • 1) MEDICAL EXPENSES

      • Unpaid medical expenses for self, spouse or qualified dependent. The medical expenses must not be covered by insurance and you must demonstrate a plan to payoff medical expenses.

    Appropriate documentation includes:

    • Copies of medical bills (dated within the last 60 days)
    • Most Recent Bank Statements- Checking and/or Savings Account(s)
    • Most Recent Credit Card Statements
    • Explanation of Benefits (EOB) documents from the insurance company (if any). Insurance documents/statements should include patient name, service dates and insurance payment information.
    • 2) HOMELESS PREVENTION

      • Imminent Risk of Homelessness; including, eviction prevention and domestic violence. Those seeking assistance in paying off their mortgage payment do not qualify.

        Definition: Individual or family who will imminently lose their primary nighttime residence, provided that: (i) Residence will be lost within 14 days of the date of application for homeless assistance; (ii) No subsequent residence has been identified; and (iii) The individual or family lacks the resources or support networks needed to obtain other permanent housing
      • Transitional Shelter Assistance for homeless persons in line with Federal Emergency Management Agency (“FEMA”) approved shelters: http://www.femaevachotels.com/index.php

        • Definition: Individual or family who lacks a fixed, regular, and adequate nighttime residence, meaning: (i) Has a primary nighttime residence that is a public or private place not meant for human habitation; (ii) Is living in a publicly or privately operated shelter designated to provide temporary living arrangements (including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state and local government programs.
      • Utilities Assistance for extreme circumstances where a home is rendered uninhabitable for lack of power, energy, water and/or gas.

    Appropriate documentation includes:

    • Copy of the eviction notice (the eviction notice must clearly indicate that legal proceedings for eviction are imminent, have already begun, or will commence within a specified timeframe if payment is not made by a specified date.)
    • Statement signed by the applicant that this home is his/her principal residence.
    • Most Recent Bank Statements- Checking and/or Savings Account(s)
    • Most Recent Credit Card Statements
    • 3) FUNERAL OR BURIAL EXPENSES FOR DECEASED PARENTS, SPOUSE, CHILD OR QUAILIFIED DEPENDENT

      • Funeral Home Expenses
      • Travel to and from funeral

    Appropriate documentation includes:

    • Copies of funeral home and cemetery bills/estimates.
    • Most Recent Bank Statements- Checking and/or Savings Account(s)
    • Most Recent Credit Card Statements
    • 4) TRANSPORTATION

      • Assistance with temporary public transportation up to thirty (30) days.
    • 5) FOR ORGANIZATIONS REQUESTING FINANCIAL ASSISTANCE

      • Proof of registration as an approved 501(c)(3) organization; specifically, IRS approved Determination Letter
    • 6) OTHER/Exception

      • Any other hardship due to unexpected, unforeseen circumstances not within the applicant’s control as determined solely at the discretion of MLBA chapter boards. All such applications must be submitted to the Program Administrator at Programadmin@livesbetter.org for review and approval.
    Have you received an MLBA grant before?
    YesNo
    If so when?

    Please note that MLBA guidelines state that more than one grant in any given calendar may not be granted.




    MM/DD/YYYY Format

    Payee Contact Information:




    *Please note if approved MLBA will only pay third party vendors directly for individual grants and not the individual grantees themselves unless approved by the MLBA Executive Board.

    *By checking the following box, you agree to grant MLBA access to privileged personal information related to this application; including, but not limited to bank records, medical records, etc. You therefore permit MLBA to contact and communicate with third party vendors and other persons/organizations to discuss and attain information related to your hardship claim. This information will be used ONLY in relation to your application and will otherwise be held in full confidentiality by MLBA staff and chapter board members.
    Check here if you accept these terms.

    PARTICIPANT CERTIFICATION, ACKNOWLEDGMENT AND AGREEMENT

    I certify that the information and supporting documentation that I have provided is complete and accurate. I have read and agree to the MLBA Application for Assistance Guidelines. I certify that if funds are requested, the amount of distribution requested above is not in excess of the amount necessary to satisfy the financial need described above, and that I have previously obtained all distributions and non-taxable loans available to me. I have exhausted all of my resources. I agree to provide the MLBA Administrator with evidence of the existence of the financial need and the amount necessary and other documentation requested to satisfy such need upon request.

    I understand that the MLBA Chapter Board (if any) and/or the MLBA Executive Board will review my application and will determine whether I qualify for the amount requested. I understand that failure to provide complete and accurate information may disqualify me from receiving any funding.



    By typing in your full name above you are digitally signing this form.