ESP International Charitable Foundation

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Loss of Life

The ESP International Charitable Foundation may help employees who are unable to pay for housing, utilities, food, clothing and other basic living expenses because of the death of the employee or eligible dependant. The Foundation may be able to help if the loss of income or the payment of funeral expenses or medical bills prevents an employee, the employee's spouse or other dependants for which the employee is financially responsible from paying for their basic living expenses. The Foundation may also be able to pay expenses to bring a child whose parent have dies to live with a new family, typically a relative. The Foundation cannot pay for travel to funerals, grave markers or funeral expense.

 

What's Covered:

 

• Medical expenses (not eligible for reimbursement by insurance)
• Temporary housing
• Security deposit for new rental property
• Essential utility bills (electricity, heat, water, etc)
• Travel for minor children required to relocate following death of parents/guardians
• Basic living expenses such as food and clothing

 

What's Not Covered:

 

• Credit card, auto and other debts
• Non-essential utilities (cable, phone, etc.)
• Lost wages
• Funeral expenses

 

Assistance Application/Vendors to be paid

 

Date of Death*

Name of ESP Employee*

Deceased is:*

 Employee

 Family Member

If family member, what relationship did the person have to the employee

What caused the death*

Did the person have life insurance*

 Yes

 No

If so, who is the beneficiary

Are there outstanding medical bills? If so, how much*

If family member, did the person who dies work outside of the home or have other income

 Outside of home

 Other Income

Describe in detail the immediate needs of the employee or the employee’s family*

How will this grant help the employee recover from the immediate financial crisis*

Please tell us anything else that would help us understand the circumstances related to the economic hardship you are experiencing

Submitted by*

Vendor Name and Address*

Basic need provided through service*

Amount owed*

Date payment due*

Account number*

Vendor Name and Address - 2

Basic need provided through service - 2

Amount owed - 2

Date payment due - 2

Account number - 2

Vendor name and address - 3

Basic need provided through service -3

Amount owed - 3

Date payment due - 3

Account number - 3

Email Address - Who submitted* Send me a copy of form

Please confirm that you are not a script by entering the letters from the image.

Important: A copy of the death certificate or obituary notice must be submitted with this application

 

 

Document Checklist: (These need to be completed before application is considered)

 

___ Assistance Application

 

___ Incident Report

 

___ List of vendors to be paid

 

___ Additional documentation as requested

 

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