CHECKLIST FOR EAP-ELF 

Print this list and bring the completed form to EAP       

Name:______________________________________ Date:________________

Have you exhausted all of the following possibilities?

               Asked Relatives/Friends

Comments:       ________________________________________________________________

                        _________________________________________________________________

         WIC (Women, Infants, and Children)                                    DHS – State Assistance

            Food Assistance                                                                       OUTCOME:                           

            OUTCOME:                                       

           Fuel Assistance                                                                       Town Assistance

            OUTCOME:                                                                            OUTCOME:                           

Please bring the following to your EAP/ELF appointment:

          Bill from vendor( up to two).  Note: We apologize, but checks cannot be made out to employee; it must             be made out to a vendor.

         Your current paycheck stub(s) as well as paystubs from all contributing members of your household.

         Statements from all checking and/or savings - printed within 7 days of your  appointment.

         Monthly Budget

         If for vehicle repair, a minimum of 2 estimates

         List credit card balances & other consumer debts