Benevolence Loan Request

You must be employed for 90 days to be eligible for assistance.

Employee in Need Information
Name of Employee in Need*
First Last
Store Location of Employee in Need*
Department of Employee in Need*
Employee Number*
Phone Number of Employee in Need*
Email Address of Employee in Need*
Employee in Need Hire Date*
MM slash DD slash YYYY
Person Making Request Information (if other than Employee in Need)
This section is ONLY required if you are the person making this benevolence request on the behalf of the Employee in Need.
Name of Person Making Request
First Last
Phone Number of Person Making Request
Email Address of Person Making Request
Benevolence Loan Request Information
Amount Requested*
Date Needed*
MM slash DD slash YYYY
Date of Last Benevolence Loan
MM slash DD slash YYYY
Amount of Last Benevolence Loan
Payback Terms*
- Weekly
- Bi-Weekly
Requested Payment Amount (Will be Payroll Deducted Each Pay Period Until the Loan is Paid in Full)*
Benevolence Loan Request Explanation*
Please explain the emergency or hardship situation. What specifically will the funds be used for? (Only under special circumstances will we make checks payable to an individual.)
Who should check(s) be made payable to?*
If multiple checks are needed, please explain below the dates and amounts of the checks needed.
Digital Signature*
By clicking here below I attest that all information I have given to complete this Request for Assistance is true and complete to the best of my knowledge. If necessary, I will provide any and all receipts to support amount of assistance given.
CAPTCHA

We Do Business Your Way!^™