COVID-19 Emergency Fund Application Step 1 of 8 12% We are fortunate to partner with you in your students’ education. That partnership extends beyond the programs and services we provide to ensuring a Miriam education is affordable and realistic for our families. We understand these are difficult times. In response to your significant financial hardship due to the COVID-19 pandemic, please complete this application to be considered for emergency funds to apply toward Miriam’s 2020-21 tuition. Please note, unfavorable market value change of your retirement and/or investment account(s) is not a qualified event for emergency funds. Additional documentation may be required based upon review of your application. Award decisions are estimated to be complete within one month of your submission. All eligible requests will be considered but funding is limited. If you have any questions, please contact Susan Bennett, Staff Accountant, at sbennett@miriamstl.org or 314-962-4177.Student Name* First Last Grade for 2020-21 academic year*PKK123456789101112Applicant Name* First Last Best phone number to reach you*Email* Preferred contact method* Email Phone Have you previously applied for a variable tuition reduction through FACTS for the 2020-21 academic year?* Yes No In addition to completing this form, submit your grant and aid application online through Miriam’s third party provider, FACTS, at this web address: https://online.factsmgt.com/signin/3CT0D and click here to read more about the FACTS grant and aid application. This application will be considered in combination with the FACTS information submitted.Please check the item(s) applicable to your circumstances:* Involuntary loss of employment Involuntary furlough or lay off from employment Involuntary reduced work hours Out of pocket medical costs due to COVID-19 pandemic Additional housing costs due to COVID-19 pandemic None of these apply to my situation You have indicated that you, your spouse, or partner has a change in employment due to the COVID-19 pandemic. Please provide the following additional information regarding this circumstance.Name of parent with employment change* First Last Employer* Last date worked* MM slash DD slash YYYY Upload a copy of the communication from your employer regarding your employment change.*Max. file size: 2 MB.Weekly wages earned at the time of your employment change* Amount of vacation and/or personal time off paid out, if any* Enter zero if noneAmount of severance received, if any* Enter zero if noneAre you eligible for unemployment benefits?* Yes No Weekly unemployment benefits received* Date your unemployment benefits began* MM slash DD slash YYYY Please indicate the reason you are not eligible for unemployment benefits.* You have indicated that you, your spouse, or partner has a reduced work schedule due to the COVID-19 pandemic. Please provide the following additional information regarding this circumstance.Name of parent with employment change* First Last Employer* Date schedule changed* MM slash DD slash YYYY Weekly wages earned prior to your reduced work schedule* Weekly wages currently earned* Date expected to return to regular work hours* MM slash DD slash YYYY Upload a copy of the communication from your employer regarding your reduced work schedule.*Max. file size: 2 MB.Are you eligible for unemployment benefits?* Yes No Weekly unemployment benefits received* Date your unemployment benefits began* MM slash DD slash YYYY Please indicate the reason you are not eligible for unemployment benefits.* You have indicated that out of pocket medical cost were incurred due to the COVID-19 pandemic. Please provide the following additional information regarding this circumstance.Amount of out of pocket medical cost incurred due to the COVID-19 pandemic* Are the out of pocket medical costs for a member of your household?* Yes No Note the relationship of the individual for whom medical costs were paid.* You have indicated that additional housing cost were incurred due to the COVID-19 pandemic. Please provide the following additional information regarding this circumstance.Purpose for the additional housing costs.*Monthly amount of additional housing cost incurred due to the COVID-19 pandemic* Number of months additional housing costs are expected to be incurred.*One monthTwo monthsThree monthsFour monthsFive monthsSix months or longerAre the additional housing costs for a member of your household?* Yes No Note the relationship of the individual for whom additional housing costs were paid.* Please explain the significant financial hardship you have incurred due to the COVID-19 pandemic.* Amount of Federal stimulus payment (also known as the Economic Impact Payment) received, or expected to be received, for your household.* Enter zero if noneEstimate your total financial losses due to circumstances related to COVID-19 considering changes in wages, unemployment benefits received, stimulus funds received, out of pocket medical costs, and additional housing costs. (Do not include change in market value for retirement and/or investment accounts.)* Amount of financial support related to these extra expenses from other resources, including family.* Enter zero if noneWhat amount of COVID-19 emergency funds are you requesting?* Other information you would like the committee to consider.I certify that the information provided in this application is truthful and complete to the best of my knowledge. Falsification of information is subject to funds being revoked. Enter your full name below as your certification.* First Last