CHECKLIST FOR EAP-ELF 

Print this list and bring the completed form to EAP       

Name:______________________________________ Date:________________

Pursuit of Other Avenues for Funds

_____ Asked Relatives/Friends

Comments:  ________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

_____ WIC (Women, Infants, and Children)  Food Assistance

_____ DHS – State Assistance

_____ Fuel Assistance

_____ Town Assistance

_____ Other Loans

____________________________________________________________________________

____________________________________________________________________________

Please provide documentation of the following: (Bank statements, check stub, etc)

_____ Savings Account Balance           _______________

_____ Checking Account Balance        _______________

_____ Salary                                        _______________

_____ Other Income                            _______________

            (ex. alimony, child support, second job)

_____ Bill(s) or invoice(s) you wish to pay with loan funds

_____ Credit Cards & Other Consumer Debts

___________________________________________________________________________

___________________________________________________________________________

4-28-06