Double R Family First Fund Application

This fund is designed to provide immediate financial assistance to employees who experience a financial hardship due to an emergency situation that is beyond their control during active employment.

Applicant must be an active Double R Restaurant Group employee at the time of the emergency in order to be eligible to apply.

Full-time employment is defined as 30 or more hours per week, and all employees (full-time or part-time) must be employed for at least one year prior to applying.

Eligible applicants can receive a maximum of one grant per natural disaster incident per calendar year and one grant per hardship incident per calendar year. Please note, the amount granted to an applicant for any incident cannot exceed the available fund balance at the time of the application, and proper documentation is required to be considered for grant assistance.

As a result of the generosity of Double R Restaurant Group, 100% of the contributions made to this Employee Emergency Relief Fund will be available to eligible employee applicants.

Select a Choice

Employee Name*

First NameLast Name

Employee ID Number*

Date of Birth *

Phone Number*

Area CodePhone Number

E-mail*

Confirmation Email

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Select a choice*

Full time (30 or more hours/week)Part time

Select a choice*

SalaryHourly

Have you been employed with the company for at least one year?*

YesNo

Which qualifying situation caused the financial hardship? (Hover over text to see definitions of the options below and choose the one that best fits your circumstances):*

Natural disasterLife threatening illness or injuryDeath incidentCatastrophic or extreme circumstances

Type of incident (ex: tornado, fire, flood, type of injury, name of illness, etc.):*

Date of Incident:*

Were you an active employee at time of incident?*

YesNo

Describe what has happened to cause your financial hardship and your immediate needs:*

Please estimate amount of immediate relief needed:*

Total household income level (should include spouse, partner, etc.):*

Your primary residence is/was:*

Owned by youRented by youNeither owned nor rented by you

What is your monthly mortgage or rental payment for your primary residence?*

What is your monthly car payment (s)?*

What are your other monthly expenses?*

Number of legal dependents at time of incident:*

Please estimate your out of pocket expenses incurred or to be incurred from damages, losses and expenditures detailed in the application that are NOT expected to be covered by insurance, government assistance, FEMA, or from other sources. Please exclude the costs associated with nonessential, luxury or decorative items and services.*

Please select ALL types of insurance coverage(s) you had prior to the incident:*

Are you requesting additional relief from other sources (ex: payments for medical or counseling services, temporary housing, etc.)?

YesNo

Where are you requesting additional relief?

How much additional relief are you requesting?

Can we share your story anonymously to help us build this program? (your identity will not be disclosed)*

YesNo

Please upload up to 6 documents/pictures substantiating your situation. These could include photo evidence of damages, invoices, insurance documents, repair estimates, death certificates, medical bills, proof of home ownership, etc.

Upload a File

I attest the information furnished above is true to the best of my knowledge. I also understand the Fund reserves the right to require and seek verification of information submitted on this application with my employer. Finally, I agree to confidentiality on the process and amounts granted to me through this employee grant process.*

YesNo

Required fields indicated by *

Personal Information

Describe Your Situation

Financial Information

Attach Supporting Documentation