A. Employee Information

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

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:

B. Unexpected Catastrophic Event

Please mark the box next to the catastrophic event that occurred:

C. Items or expenses for which you need assistance paying

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 certify that:

• All information provided is accurate and truthful.

• 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:

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