Hertz Disaster Application

The Hertz Corporation
Employee Louisiana Disaster Relief Fund

 

Application

Grants will provide assistance to The Hertz Corporation employees experiencing need caused by the August 2016 Louisiana Floods, a federally-declared disaster.

Employee ID#:

Last Name (required)

First Name (required)

Middle Initial (required)

Street Address (required)

City (required)

State (required)

Zip (required)

Number of dependants

Cell # (required)

Your Email (required)

Property / Location (required)

Title (required)

Department (required)

AID REQUESTED

Food

Estimated amount needed $


Clothing

Estimated amount needed $


Temporary housing

Estimated amount needed $


Housing (including repairs)

Estimated amount needed $


Transportation

Estimated amount needed $


Medical assistance(including psychological counseling)

Estimated amount needed $


Other, please specify

Estimated amount needed $


How can we provide funds to you directly and quickly?

Note: Receipts for reimbursement or direct payment of expenses will be required.

DISCLOSURE

Conflict of Interest:
Are you or any of your family personally related by marriage or birth to any officer, director or substantial contributor to the Southwest Florida Community Foundation or The Hertz Corporation?
 Yes No

If yes, please explain your relationship

Declaration:
By signing below, under penalty of perjury, I declare, to the best of my knowledge and belief, that the above stated information is true and correct. Additionally, I authorize The Hertz Corporation to disclose my name and contact information to the Disaster Fund Committee and/or the Southwest Florida Community Foundation as it pertains to the above emergency. I agree to provide copies of receipts for any direct payment and/or reimbursement of expenses on my behalf. I further authorize the Southwest Florida Community Foundation to disclose any confidential and/or financial information to other community resources to determine if I am eligible to receive assistance.

Electronic Signature

Date

The Disaster Relief Fund Committee will not consider incomplete applications. If you have not received a response to your application within 4 business days or if your needs require immediate attention (i.e. 24 hours), please contact the Southwest Florida Community Foundation at (239) 274-5900 or email [email protected].