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 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)

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)

United 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 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

Appropriate disclosures, authorizations

Electronic Signature(Required)

Today's Date(Required)