Application – The CAUSE Foundation®

Check List

Thank you for requesting information from The CAUSE Foundation. This checklist is provided to assist you in filling out your application. Please initial as each item as you read it, sign it below and return it with your completed application. Failure to return this checklist will delay the processing of your grant application.

Once your application is approved, it is your responsibility to contact your domicile CAUSE Representative by the 5th of each month regarding your grant continuation. Failure to do so will result in no funds issued for that month. In addition, a review of an ongoing application will occur every three months. Updated documentation is required at least every six months or as requested. *

An application form must be filled out completely and signed by the applicant and CAUSE Representative. The “Amount Requested” space must be filled in. Monetary amounts must be stated in US currency. *

Current medical documentation signed by your doctor must accompany the application or be sent to the CAUSE Representative. It is your responsibility to provide updated documentation every six months. (Please contact your CAUSE Rep for process of getting this information to us.) *

Copies of both the 1st and 16th paycheck stubs for the previous two months prior to your last day worked must accompany your application. *

Copies of spouse’s/domestic partner’s (if applicable) paycheck stubs for the previous two months must accompany your application. *

Copies of all pages of your bank statements for the past two months must accompany your application *

A copy of your most recent 401K Statement must accompany your application *

Documentation of sick leave balance must accompany your application. *

Copies of federal income tax returns (Form 1040) for the previous two years must accompany your application. W-2’s do not constitute tax returns and will not be accepted as such. The CAUSE Foundation reserves the right to request further financial documentation. *

If you are single/divorced with dependent children and not receiving child support, a copy of the divorce decree and custody agreement with child support agreement must accompany your application. *

If this application is related to a work related injury, copies of appropriate documentation (accident report, pay stubs and check copies, including Workers Comp checks) must accompany the application. *

If you are in litigation in conjunction with the illness or injury listed on this application and receive a settlement, it would be appreciated if you would consider making a donation to The CAUSE Foundation so that we may continue to help other flying partners in need. *

All applications must have the appropriate documentation in place before checks can be issued. No exceptions! Please make copies of all paperwork for your personal file. *

Signature

Clear Signature

Please enter your CAUSE Rep's name that you have been working with (If you have not contacted a Rep please do so prior to continuing.) *

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THE CAUSE FOUNDATION APPLICATION FOR GRANT

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Base *

U/File Number *

Seniority Date *

Birthdate *

Name and Ages of Dependents

(Dependents listed MUST be claimed on your tax return to be consider for the purposes of a grant.)

Brief description of disability and/or illness and date of onset *

Please upload a note from your Medical Doctor explaining your disability and/or illness *

Click or drag files to this area to upload. You can upload up to 7 files.

Files accepted are pdf, png, gif, and jpg

Work Related? *

Yes
No

Last Day Worked *

Approximate Return Date (If known)

Health Insurance Provider *

Are you requesting this grant for medical bill payments? *

Yes
No

Have you or are you applying for other assistance/grants? (i.e. United We Care, Churches, etc.) *

Yes
No

Have you applied for Disability Benefits *

Yes
No

Have you or a household member previously applied for a CAUSE grant? *

Yes
No

Have you declared bankruptcy in the past 24 (twenty-four) months? *

Yes
No

Current Sick Bank Balance *

Please provide documentation of your current sick leave bank balance. *

Click or drag a file to this area to upload.

Files accepted are pdf, png, gif, and jpg

Monthly Amount Requesting (Monetary amounts must be stated in US currency) *

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MONTHLY INCOME (US $$)

If you don’t have any income in a certain category please put a 0 (zero)

The CAUSE Foundation certifies that any and all information obtained to support this application will be kept confidential by the persons signing this application and their officers.

It is the policy of The CAUSE Foundation to review each grant application without regard to an individual’s race, creed, color, religion, sex, age, national origin, nature of disability or sexual orientation.

Current United (NET) *

Please upload your last 2 (two) months pay stubs from United (when you actually worked). *

Click or drag files to this area to upload. You can upload up to 4 files.

Files accepted are pdf, png, gif, and jpg

Social Security Disability *

State/Foreign Disability *

Short Term Disability *

Long Term Disability *

Alimony/Child Support *

If you are NOT receiving your court awarded child support, please attached documentation explaining what steps you are taking to pursue collection.

Please provide a copy of the divorce decree and custody agreement with child support agreement if you are single/divorced with dependent children and not receiving child support

Click or drag files to this area to upload. You can upload up to 3 files.

Files accepted are pdf, png, gif, and jpg

Additional Income *

Pension Income *

Social Security Income *

Signature *

Clear Signature

I, the undersigned, certify that all of the statements and representation of this application constitute a true and accurate account of my illness/disability and financial condition as of the date below. I have attached, in support of this application, requested documentation. Fraudulent use of The CAUSE Foundation will cause forfeiture of all future benefits and may result in criminal and/or civil litigation and prosecution. Additionally, CAUSE will investigate all possible avenues of recouping monies obtained under false pretenses.

I, the undersigned, on my behalf or as guardian of another, authorize THE CAUSE Foundation to release information to its Board of Directors, employees and volunteers as necessary with regard to my grant application. I give the above authorization with the recognition of my privacy rights under the Health Insurance Portability and Accountability Act and the Final Rule promulgated under HIPAA, 45 CFR Parts 160 and 164.

Other Income (be specific)

Other Income Amount

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ASSETS

If you don’t have any income in a certain category please put a 0 (zero)

The CAUSE Foundation certifies that any and all information obtained to support this application will be kept confidential by the persons signing this application and their officers.

It is the policy of The CAUSE Foundation to review each grant application without regard to an individual’s race, creed, color, religion, sex, age, national origin, nature of disability or sexual orientation.

Checking Balance *

Savings Balance *

Please provide all pages of your bank statements for the past 2 (two) months *

Click or drag files to this area to upload. You can upload up to 2 files.

Files accepted are pdf, png, gif, and jpg

Value of 401k/IRA *

Please provide a copy of your most recent 401K/IRA statement

Click or drag a file to this area to upload.

Files accepted are pdf, png, gif, and jpg

Investments

GoFundMe or other crowdsourcing funds *

Do you have an Alliant Credit Union Account *

Yes
No

Alliant Credit Union Member Number *

* If you do not have one please put n/a

Other Assests *

Please upload your tax returns for the past 2 (two) years. (Only the first two pages of each tax year is required)) *

Click or drag files to this area to upload. You can upload up to 9 files.

Files accepted are pdf, png, gif, and jpg

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MONTHLY EXPENSES

If you don’t have any income in a certain category please put a 0 (zero)

The CAUSE Foundation certifies that any and all information obtained to support this application will be kept confidential by the persons signing this application and their officers.

It is the policy of The CAUSE Foundation to review each grant application without regard to an individual’s race, creed, color, religion, sex, age, national origin, nature of disability or sexual orientation.

Mortgage/Rent (Your Responsibility/Share) *

HOA Fees (if applicable) *

Food *

Health Insurance *

Cell Phone Expense *

Utilities *

Medicines *

Car Payment(s) *

Auto Insurance *

Alimony/Child Support *

Cable/Satellite/Internet/Phone *

Credit Card Payments *

Total Owed on Credit Card(s) *

401K Loan Payment(s) *

Other Loan Payment(s) *

Child Care *

Other Expense

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CERTIFICATION OF DISCLOSURE *

I do hereby certify that I have truthfully disclosed all information requested by The CAUSE Foundation in regard to my pending application. If any part of the information submitted is found to be fraudulent it will result in my application being denied and I will return any monies already paid to me by The CAUSE Foundation. I will then be denied any future requests of The CAUSE Foundation. I will inform The CAUSE Foundation of any change in my United Airlines employment status such as base transfer, retirement, furlough or other separation from the company at the onset of that status change. I will immediately inform The CAUSE Foundation when I return to active status. If my flying records are restricted from view so that my CAUSE representative does not have full access to my schedule, grant payments will cease. This certificate informs me that checks may be made out, at the discretion of the CAUSE committee either to the Flight Attendant, institution or provider of services. The CAUSE Foundation may provide financial assistance for up to nine months. If the illness or injury exists past that nine months, a new application may be submitted no sooner than one year following the previous termination of grants. The CAUSE Foundation is not in a position to grant emergency funds. Grant approval can take two to six weeks. Timely processing of grants is dependent on how quickly my completed application is submitted. Checks will be mailed by the 15th of each month barring unforeseen circumstances.

Date *

Signature *

Clear Signature

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Miscellaneous

Anything else you would like The CAUSE Foundation to know?

Please upload any other documents that may have been requested by a CAUSE Rep here. *

Click or drag files to this area to upload. You can upload up to 9 files.

Files accepted are pdf, png, gif, and jpg

Captcha (Please answer the following math problem. If you receive * you multiply the numbers) *

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