Fields marked with an * are required

Incomplete applications will not be processed.

3. Address

9. I am impacted by the COVID-19 Virus in the following way (check all that apply):*

10. I am requesting financial assistance for the following expenses as a result of being impacted by the COVID-19 Virus (check all that apply):*

Submit both of the following:

  • Mortgage statement or rental agreement only where a lender or landlord has not delayed payments.
  • Document from Mortgage company or rental company on company letterhead stating they will not delay payments.
  • Submit a copy of your bill

Submit both of the following:

  • A statement from the daycare or elder-care provider indicating the amount currently due, and any special COVID-19 payment arrangements made by the provider.
  • The day-care center or child-care provider’s tax ID number.

Submit the following:

  • If the expense is on you, a copy of the Explanation of Benefits Form providing details on the amount paid by their insurance.
  • If the expense is on a household member, a copy of the family member’s Explanation of Benefits Form providing details on the amount paid by their insurance.

Please email all supporting documents to lstaggs@srhs.com with the subject line "COVID-19 Employee Emergency Fund Application Supporting Documents".  Supporting documents should be submitted within 24 hours of submitting this application. Applications will not be considered unless supporting documents have been submitted.

Your request for financial assistance will be held in the strictest of confidence by the Administrator of the Spartanburg Regional Foundation COVID-19 Employee Emergency Fund. Human Resources may be consulted to confirm your working hours, unemployment received, or furlough pay received and other information needed by the committee.