Serving New Mexico Relief Fund Application

The Serving NM Fund is a safety net for workers who are employed but are experiencing general hardship. We provide financial assistance in the form of grants to those in crisis due to an unexpected illness, injury, or natural disaster. Please note that this form has 4 pages.

Serving NM Relief Fund grants are available for any New Mexico restaurant or hospitality worker who:

Is a full-time resident of the state of New Mexico.
Has a primary source of income rooted in food and beverage and is currently employed in the restaurant or hospitality industry.
Has experienced an emergency that’s an unexpected, non-recurring crisis within the last 6 months.
Works for a NM Restaurant Association member.

Unanticipated hardships necessitate prolonged, unpaid absences from work and generally fit into one of the following categories:

Injury caused by an accident (such as a slip, fall, or crash) requiring hospitalization or other acute care.
Illness requiring hospitalization or other acute care.
Death or catastrophic illness or injury of an immediate family member imposing a financial or full-time care giving burden on the worker.
Disaster, such as flood, fire, or storm damage (to name a few) causing disruption of a worker’s job or ability to work.
Acts of violence in which the employee is the victim.

In order to have your Serving NM Relief Fund application reviewed, you must upload the following documentation:

Required - Proof of New Mexico residency ie., NM Driver’s License, NM I.D., signed lease document, or any bill from a utility company that shows the service address.
Required - Proof of current employment Last two (2) paystubs from a NM restaurant or F&B hospitality business.

Fields marked with an * are required.

Page 1/4

Applicant Information
Please make sure that you have the correct mailing address, apartment/unit/lot, city and zip code. Any incorrect information will delay your application processing.

First Name *

Last Name *

Address Line 1 *

Address Line 2

Apartment number, lot number or unit number if it applies.

City, State, Zip Code *

Phone *

Please be sure to include a phone number for us to contact you. If we can not reach you, your application may be postponed.

Email *

Page 2/4

Statement of Need
This is your opportunity to tell your story to our review committee. Please give as much information as possible about what happened and why you are applying for a grant with the Serving NM Fund. • What is your unanticipated hardship? • When did it happen? Use specific dates. • How much work have you missed so far? Use specific dates. • How much work do you expect to miss in the future? • How has this hardship affected you financially?

How did you hear about the Serving NM fund? *

Check all that apply.

Employer?

Friend?

News/Media?

Other

What category does your hardship fall into? *

Please choose the category that fits the best.

Injury caused by an accident (such as a slip, fall, or crash) requiring hospitalization or other acute care

Illness requiring hospitalization or other acute care

Death or catastrophic illness or injury of an immediate family member imposing a financial or full-time care giving burden on the worker

Disaster, such as flood, fire, or storm damage (to name a few) causing disruption of a worker’s job or ability to work

Acts of violence in which the employee is the victim

Statement of Need *

This is your opportunity to tell your story to our review committee. Please give as much information as possible about what happened and why you are applying for a grant with the Serving NM Fund. There is a 500 Character limit. If you need to explain in more detail please upload a document.

• What is your unanticipated hardship?
• When did it happen? Use specific dates.
• How much work have you missed so far? Use specific dates.
• How much work do you expect to miss in the future?
• How has this hardship affected you financially?

You may upload this information in a word document. If you choose to do this please indicate UPLOADED Document in the text box so that we know to look for it.

Statement of Need File Upload

Please use this section to upload your document for your statement of need.

20MB max

Page 3/4

Employment History
Please provide your most recent employment information. You will need to upload your employment history for the last two years starting with the most recent/current.

Organization *

What Organization (company) do you work for? Please be sure to use the correct company name, not abbreviations.

Direct Manager Name *

Please include their First AND Last name.

Phone *

Business or Supervisor's phone number.

Address Line 1 *

Work address.

City *

Work City, please do not abbreviate.

Postal Code *

Business Zip Code.

Work Status *

Are you Full Time (40 hours per week) or Part Time?

Full Time

Part Time

Your Position *

Tell us about your position. What duties do you perform?

Hire Date *

Last date worked *

FOH or BOH *

Do you work in the Front of House or Back of House?

Front of House directly serves the customer, Back of House serves the front of house (rarely interacts with the customer).

Front of House

Bank of House

Still Employed? *

Are you currently working? On a leave of absence?

Currently Working my regular schedule

Working a reduced schedule

Unable to work

On a leave of absence and plan on going back

On a leave of absence and not sure if I will return

Hourly Wage? *

Please indicate your hourly wage (do not include tips, only your base rate).

Do you receive Tips? *

Please enter the amount of tips you typically receive weekly. If you do not receive tips please enter 0 (zero).

Employment History Upload

Please upload 2 years of employment history or resume. Please include the information from above.

Organization
Direct Manager Name
Phone number
Address with City and Zip Code
Full-Time or Part-Time
Position
Hire Date
Last Date worked
Why did you leave
Hourly wage
Tips

20MB max

Page 4/4

Living Expenses

Do you rent or pay a mortgage? *

What is the monthly amount?

Utilities *

Are you responsible for gas, electrical, and water bill? What is the monthly average of the utilities?

DO NOT include any cell phone costs.

Disclosure Statement
By submitting this application, I am electronically signing it and declaring, under penalty of perjury, that the information provided is true and accurate to the best of my knowledge. I understand that the Serving NM fund may use this information to assess my qualifications for receiving a grant and may share it with others as needed. I acknowledge that receiving funding from the Serving NM fund is not guaranteed.

Signature *

If I am awarded a grant, I confirm it will only be used for expenses related to the situation described in my application. I also allow the Serving NM fund to share my name and the grant amount, if awarded, to fulfill its purposes and legal requirements.

Please type your full name in the box that you understand and agree to the above policies. This will be considered your signature.

Forms

Please upload the following items if you did not upload them on prior pages:

Employment history (2 years including your current employment)
Last 2 Paystubs from a NM restaurant or F&B hospitality business.
Proof of New Mexico residency, NM Driver’s License, NM I.D., signed lease document, or any bill from a utility company that shows the service address.

20MB max

Powered By GrowthZone

Serving New Mexico Relief Fund Application

Please verify that you have checked the “I'm not a robot” checkbox.

Page 1/4

Page 2/4

Page 3/4

Page 4/4