Application for Assistance

Please complete this form in its entirety. It is essential that you provide current and accurate information. Any documentation that you have that supports your claim should accompany this application to ensure there are no delays in evaluating your requests.
Please keep a copy of the completed form for your records.

To qualify for a grant, you must be employed in local, Louisville-area independent restaurant for 6 months.
You must apply no later than 6 months after onset of need.
Once a grant is awarded, Apron, Inc. pays creditors directly for the amount(s) owed.

Mail: APRON, Inc.
291 North Hubbards Lane
Ste. B26-266
Louisville, KY 40207

Questions - Call or email APRON, Inc at (502) 403-5683 or garyf@aproninc.org

COMPLETE SECTIONS 1 - 4

Section 1 - Employee Information

Application for Assistance

Name *

First

Last *

Last

Current Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Telephone Number *

Alternate Number

Email *

Restaurant *

Restaurant Address *

Restaurant Phone *

Manager/Owner's Name(Please specify) *

Manager/Owner Phone *

How long have you been consistently employed in the local restaurant industry? *

Have you applied to APRON, Inc, before? *

Yes

No

If so, did you receive assistance? *

Yes

No

When did you apply?

Section 2 - Description of Hardship

Please check if this is a *

Catastrophic Event

Financial Hardship

Other

Date of Disaster/Financial Hardship *

(Must be triggered by an unavoidable event - illness, death, accident, crime or other personal event)

Was it beyond your control? *

Yes

No

Do you or any member of your household or family have other insurance coverage or any other financial resources to assist with this hardship? *

Yes

No

If yes, please explain

Description of your hardship and the resulting financial consequences *

Section 3 - Amount of Assistance Requested

Please provide an itemized list of your assistance request with Description and Actual/Estimated Cost *

Grand Total $ *

Amount of Assistance requested $ *

Section 4 - Your Financial Resources and Other Expenses


Homeowner's/Renter's Insurance (complete if request is related to loss of primary residence)

Do you rent or own? *

Rent

Own

Do you have Homeowner's/Renter's Insurance? *

Yes

No

If yes, is this loss covered? *

Yes

No

Auto Expenses (complete if request if automobile related)

Do you have Auto Insurance? *

Yes

No

If yes, is this loss covered? *

Yes

No

Will Auto Insurance cover medical expenses? *

Yes

No

Will Auto Insurance cover lost wages *

Yes

No

I did everything in my power to avoid or prevent this event or hardship. I have done everything possible to help myself before applying for this assistance. I certify that the information contained in this application is true, correct and complete and that I am requesting assistance because of a severe financial hardship that is not covered by insurance or any other sources.

Employee Signature (or Delegate) *

Date *

Relationship to Applicant *

It is our goal to process your application as quickly as possible.

May we use your story for future public relations and/or fundraising activities *

Yes

No

(Answering no will not impact APRON'S decision to fund or not fund your request for assistance.)

Are you willing to volunteer for upcoming APRON, Inc activities? *

Yes

No