Caddo Schools Employee Assistance Fund (CSEAF) Name(Required) First Last Employee ID #(Required) Job Title(Required) Immediate Supervisor(Required) Work Site(Required) Work Site/School Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Email Address(Required) Enter Email Confirm Email Current Employment Status(Required) Hire Date If you are unsure of your hire date, please select the year only. Primary Phone Number(Required)Marital Status(Required) Date of Birth(Required) MM slash DD slash YYYY Sex(Required) Male Female Nonbinary Monthly Household Income(Required) Monthly Expenses(Required) Health Insurance(Required) Other Monthly Expenses(Required) Number of Children Living in Your Home(Required) What are the ages of the children living at the above address?Need for financial assistance:(Required)Please describe the situation that has caused your recent financial emergency.Resources obtained from 2-1-1(Required)Request for PaymentUnited Way of Northwest Louisiana will pay the vendor on your behalf. Please ensure all information is correct below.Amount Requested(Required) Payee Name(Required) First Last Payee Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How do you want to receive your check?(Required) Pick up the check Mail the check to the Payee Address listed above Permission to Share Information(Required) Yes No Appropriate disclosures, authorizationsElectronic Signature(Required) Reset signature Signature locked. Reset to sign again Today's Date(Required) MM slash DD slash YYYY Δ