GMS Family Fund, Inc.

(Please select the phone number where you prefer to receive calls regarding this application.)

Please select your preferred payment method:

Check

Prepaid Debit Card

Electronic Funds Transfer to payroll account (must initial ACH authorization below if selected.)

Above named Employee hereby authorizes The GMS Family Fund, Inc. to originate an Automated Clearing House electronic funds transfer (ETF) credit entry to Employee’s bank account on file with Gypsum Management and Supply, Inc., used for payroll purposes, as indicated below:

Application Submission Requirement Checklist:

You must complete the following requirements. Please be advised that submitting an incomplete application will result in a delay as an incomplete application will be returned to the applicant for resubmission with all required documentation.

Copies of bills for which you are requesting assistance.

Documentation (proof) of the catastrophic event. (Fire Marshal’s report, Police report, accident report, etc.) (NOTE: For Presidential declared natural disasters or catastrophic home loss, no proof of catastrophic event is required. Manager confirmation of loss or photos of the loss will be accepted.)

Application is completed in its entirety.

B. Unexpected Catastrophic Event

Illness of

Injury of

Death of

Natural Disaster

OTHER/EXCEPTION REQUEST The above-listed items are generally eligible for assistance from The GMS Emergency Assistance Fund. However, if you have suffered an unexpected catastrophic event not listed, please provide as much detail and documentation about your event as possible. Each request is given consideration based on its specific circumstances.

DETAILS OF UNEXPECTED CATASTROPHIC EVENT Please describe the details of your situation in specific details. (Use a separate piece of paper, if needed.)

C. Items or expenses for which you need assistance paying

Please list the item(s) or expense(s) for which you are seeking assistance paying in order of importance including the dollar amount.

D. Other resources

Please indicate the amount of assistance you have already received or expect to receive from the following resource(s).

E. Certification & Authorization

• I am personally and solely financially responsible for the expenses for which I am seeking reimbursement. There are no other family members of sources of reimbursement (insurance, charitable organizations, government relief, etc.) for these expenses.

• I am claiming reimbursement only for events that are valid under the Approval Committee Guidelines.

I authorize the GMS Family Fund Approval Committee to validate the information provided on the application as part of the review process. If necessary, the GMS Family Fund Approval Committee has my permission to contact Human Resources to verify information.

Signature of and contact information for person submitting application on behalf of employee:

A. Employee Information

Application Submission Requirement Checklist:

B. Unexpected Catastrophic Event

C. Items or expenses for which you need assistance paying

D. Other resources

E. Certification & Authorization