Haworth Member Relief Fund Application Form

Haworth Member Relief Fund Application Form

If you are a Haworth North America member facing a qualifying financial hardship and wish to apply for a grant from the Haworth Member Relief Fund, please complete the application form below.

Your application will be submitted for review to the Helping Hands Charitable Foundation, the third-party 501(c)(3) organization that manages our relief fund. They will contact you directly if they have any additional questions necessary to assess your application for approval.

Member Eligibility: This program is available to regular full-time and part-time Haworth North America Commercial Interiors members.

Member Information

Member Name*

First NameLast Name

Member ID Number*

Numerical Member ID, not 4-digit User ID

Member Email*

example@example.com

Member Phone Number*

Please enter a valid phone number.

Preferred Method of Contact*

PhoneEmailBoth

What is the best time to contact you?*

Member Home Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Description of Need

What is the reason for your financial hardship?*

Natural Disaster or Catastrophic Event (e.g., fire, hurricane, flood, tornado, etc.)Loss of an Immediate Family Member (Haworth Member, Spouse, Domestic Partner, Child)Serious Illness or Injury

How much assistance do you feel is needed?

Please enter an amount up to $1,000.

Please provide details about your financial challenge and why you noted the specific amount above. *

Number of Dependents*

Please note the number of people you provide for.

Applicant's Monthly Income

Please provide your household monthly income.*

	Applicant	Spouse	Other(s) in Household
Wages (Net)
Child Support/Alimony
Social Security Income/Disability

Grand Total Monthly Net Income:*

Applicant's Monthly Expenses

Please provide your household monthly expenses.*

	Monthly Amount	Unpaid this Month
Rent/Mortgage
Utilities
Phones
Car Payments
Car Insurance
Health Insurance
Child Care
Food
Transportation
Medical Expenses
Loans
Garnishments
Other

Grand Total Monthly Expenses: *

Please provide comments to help explain the information you provided above.*

Confidentiality Disclosure

Personal information provided in this application and in correspondence with the Helping Hands Charitable Foundation's project coordinators will remain confidential. On occasion, aggregated, de-identified data may be shared with select third parties for non-commercial purposes. Helping Hands Charitable Foundation will never require you to disclose the contents of this application with your employer or any other benefactor as a condition of eligibility.

Applicant Certification

By signing this form, I consent to the collection, use, and sharing of my personal information as described herein for the purpose of the Helping Hands Charitable Foundation to evaluate my request. I also certify that the above information provided on this application is true and correct to the best of my knowledge, and that the knowing submission of any false or misleading information will result in my application being denied without further review. I acknowledge that submission of this application does not guarantee that Helping Hands Charitable Foundation will grant me the requested assistance.

Member Signature*

Date*

Please note:

Helping Hands Charitable will provide the Haworth Helps HR program manager with your name and member ID to confirm your employment.
After employment verification, you will be contacted by a representative from the Helping Hands Charitable Foundation within 48 hours (excluding holidays and weekends). Their project coordinators are trained to speak with you and conduct the necessary due diligence required to determine eligibility for a grant in a private and secure manner. After the review process, they will let you know if an award will be made to you for some or all of your requested amount.