COVID-19 Hardship Relief Request Form

The Board of Directors has authorized this assistance program for members hardest hit by the 2020 work stoppage. See more info about this and other measures taken by the Board, including low-interest loans and no-interest monthly payment plans.

IMPORTANT:

Applications for COVID-19 Hardship Relief were accepted through December 31, 2021. The Business Agent must approve all inquiries to apply after this date. It is the Board of Directors’ discretion to review these applications on a case-by-case basis.
All information submitted on this application form will be held in strictest confidence and will only be viewed by the Local 695 Board of Directors and only for the express purpose of determining eligibility for this COVID-19 Hardship Relief program.
To be eligible, you must have been an Active Member at the time of the March 2020 industry shutdown. And at the time of application, your dues must be paid up through at least the 4th quarter 2019.
Your combined total of all bank and brokerage accounts (excluding retirement accounts) may not exceed $12,000.
Members may request 4 quarters of COVID-19 Hardship Relief forgiveness on Dues and Per Capita at the 2020 rates.
Should any information submitted on the COVID-19 Hardship Relief application form be proven false after Hardship Relief is awarded, the member is responsible for immediate and full repayment of Hardship Relief received.
Funds for this program are limited and will be awarded on a first-come first-approved basis for those in greatest need.
All questions below must be answered in order for this application to be considered.
By applying for financial assistance through Local 695, the Applicant agrees and acknowledges that her/his Personally Identifying Information (“PII”) and/or Confidential Information (“CI”) may be accessed, reviewed and relied on by Local 695 and/or its agents. The Applicant waives any and all recourse against Local 695 with respect to any such access to PII and/or CI.

Name*
First Last
Email*
Phone*
Last Four of SSN*
Classification*
Please explain your reasons for making this request. Include any extenuating circumstances.*
Approximately how many days did you work last year? (Please note: We may verify with MPI)*
What was your total income for 2020/2021?*
How much have you been working since January 2021 and do you have any work opportunities lined up?*
Is there anything else that is important for us to know? *
Your combined total of all bank and brokerage accounts (excluding retirement accounts) must be less than $12,000. Please include your most recent copies of all bank and brokerage statements (excluding retirement accounts), as well as a recent mortgage/rent statement*
Drop files here or

Max. file size: 10 MB, Max. files: 10.
E-Sign*
I hereby certify that all the above information provided for COVID-19 Hardship Relief is accurate and true. Should any of the above information be proven false after Hardship Relief is awarded, I understand and accept responsibility for immediate and full repayment of Hardship Relief received.
Date Submitted*
MM slash DD slash YYYY
Please allow up to a maximum 4 weeks for review of this request.