Willie Lopez Emergency Assistance Fund Grant Application

Willie Lopez Emergency Assistance Fund Grant Application
Date

MonthDayYear
To learn about the details of the application process and to see qualifying situations please visit our Applying for Assistance Page.

Please complete all required fields before you click, or tap Submit. Required fields are marked with a red asterisk. When you submit the form, you will receive an e-mail with the completed application.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Store or Office Number*
Company*
Number of Adults in Household*
Number of Children in Household*
Are you a current employee of Tailored Brands, Inc. or one of its subsidiaries?*

YesNo
Is your job with Tailored Brands, Inc or one of its subsidiaries full-time, part-time, or seasonal?*

Full-timePart-timeSeasonal
What is your job title?
What is your relationship with the employee?
Do you currently have a 401k?*

YesNo
What is the nature of your emergency? *

Please write or type in the space below the complete details concerning the cause and extent of your financial emergency. Please use pronouns (such as, I, me, they, him her, etc.) in place of personal names to protect the privacy and identity of individuals involved. This information will be reviewed by the Selection Committee charged with making the Fund’s decision on your application. However, your name and other personally identifiable information will be hidden so the Selection Committee will not know your identity or any other individuals involved.*

0/500
Below, please fill in your current monthly living expenses in the chart provided and include any past due amounts if applicable. Use the space below the chart for any other additional financial responsibilities not already listed that will assist in understanding your financial need during this particular emergency.

Please save all receipts for purchases made with any grant money that you may receive. During disaster emergencies such as hurricanes, receipts may be required for any purchases directly related to the disaster (i.e. gas, food or hotel due to evacuation).

When renting from an individual, the landlord will be required to provide proof of ownership (i.e. property tax bill or Deed of Trust) and a lease or rental agreement before any payments are made for rent.

Monthly Expenses*

	Monthly Amount	Past Due Amounts	Notes
Rent or Mortgage (Please sprecify in notes)
Insurance (car, house, rental)
Car Payment(s)
Phone/Internet/Cable
Utilities (electricity, water, gas)
Credit Cards (minimums only)
Groceries
Gas/Transportation
Medications and Co-Pays (minimums only)
Loans (minimums only)
Day Care
Other (Please specify in notes)
Other (Please specify in notes)
Other (Please specify in notes)
Total Monthly Expense

Monthly Household NET Income (Include all income sources i.e. spouse, social security, unemployment, etc.)*
Please use the space below to describe any financial obligations you may currently have that are out of your ordinary monthly expenses.

I hereby certify that the facts set forth in this grant application are true and complete to the best of my knowledge. I understand that if awarded a Fund grant, falsified statements on this application shall be considered sufficient cause for appropriate steps to recover the proceeds previously paid. Keep in mind that the Code of Conduct in the Employee Handbook expressly prohibits falsifying records, misappropriating, taking or borrowing Company funds, and acting in a dishonest manner. Any employee who makes false statements to obtain a Fund grant violates those and other Company policies and will be subject to disciplinary action up to and including termination. The Company will also obtain any misappropriated Company funds through wage deductions and/or criminal prosecution in its sole discretion and to the full extent permitted by law.

I understand that I am providing, and agree to further provide as reasonably requested, personally identifiable, personal information about myself and/or my family, including but not limited to social security numbers or other identification numbers and financial information (“Personal Information”). By submitting this Application, I authorize the Fund to share Personal Information with Tailored Brands, Inc. and the Fund’s Selection Committee, to assist the Fund in making a decision on my Application. And, if I am selected for a Grant, I expressly authorize the Fund to share Personal Information with Tailored Brands, Inc. and/or other unaffiliated third parties, including but not limited to credit card and banking companies and health care institutions, to administer the Grant. In these situations, the Fund does not authorize these third parties to use Personal Information for any other purpose.

I also authorize the Fund to disclose Personal Information when (a) the Fund believes the law requires such disclosure, (b) in response to legal process and law enforcement requests, and (c) as necessary to protect the property, interests, and rights of the Fund.

Finally, in the event all or a portion of the assets owned or controlled by the Fund are sold, assigned, transferred or acquired by another company, both personally identifiable information and aggregate non-personal information from and/or about our customers may be among the transferred assets.

I understand that the Fund makes all its award decisions according to the IRS approved Grant Procedures, and I will therefore, have no ill will if I am denied an award, for whatever reason.
Signature*

Clear
Short Name*
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