Barbara B. Holt Employee Assistance Fund Program

The Barbara B. Holt Employee Assistance Fund was created to provide relief to eligible Better Communities Collaborative (and its affiliated companies) employees experiencing economic hardship and are unable to afford housing, utilities, and other basic living needs because of natural disaster, life-threatening illness or injury; death or other catastrophic or extreme circumstances beyond the employee’s control (generally referred to as ‘qualifying incidents’.) Please complete this form and attach documentation regarding your qualifying incident to be reviewed by an external committee.

Full Name *

First

Last

Phone: *

Email *

BCC Company Employed by:

(ex: W&A Engineering, GroundHawk, etc.)

Length of Employment:

Employment Start Date:

Qualifying Incident:

• Natural Disaster
• Life-Threatening or Serious Illness or Injury
• Death Incident
• Catastrophic or Extreme Circumstance

Please check one above.

Date of Qualifying Incident:

Description of the Qualifying Incident:

Amount of Assistance Desired:

Additional information, if you would like to provide more about the assistance needed:

Please attach documentation regarding your qualifying incident.

Click or drag files to this area to upload. You can upload up to 10 files.

Submit