Personal Information

First Name*

Middle Name

Last Name*

Date of Birth*

Social Security Number*

Gender*

Race/Ethnicity*

Do you have a disability?*

Home Address*

Apartment No.

City*

State*

Zip*

Personal Email*

Home Phone

Cell Phone*

Association Memberships

Membership in a union or association is not required for this program.

Other Association Membership Name

Are You a Veteran?

Total Number of Members of Household (including self)*

Household Members Detail (tell us who lives in your home and their relationship to you)*

Where did you learn about this program?*

Other way you learned about this program

Employment Information

Federal Agency*

Position/Title*

Work Phone (your direct line/extension)*

Work Email*

Agency Address*

Agency City*

Agency State*

Agency Zip*

GS Grade

Annual Salary*

Immediate Supervisor*

Supervisor Phone*

Payroll Contact*

Payroll Contact Phone*

Emergency Information

What is the Reason for Your Loan Request? (please see Loan Application Instructions at www.feea.org/emergency for important information)*

What expenses are you seeking payment for?*

Please describe how the emergency situation selected above caused you to seek a loan from FEEA*

Monthly Income

Are you in the process of filing, or have you filed for, had a discharge of, or paid off a bankruptcy within the last 5 years?*

*Please note: if you answered "yes" to this question, you are not eligible for FEEA's loan program.

Please type "0" if this income doesn't apply

Net Pay of Federal Employee Per MONTH (if you are paid bi-weekly please multiply by 2)*

Net Pay of Spouse per Month*

Net Disability or Retirement Income Per Month*

Net Child Support Income Per Month*

Net Alimony Income Per Month*

Net Unemployment Insurance Per Month*

Other Net Income Per Month*

Please Specify Source of Other Net Income

Monthly Expenses

Please type "0" if this expense doesn't apply

First Mortgage Payment*

Second Mortgage Payment*

Monthly Rent*

Child Support Expense*

Auto Payment*

Credit Card Payment*

Other Debt Payment*

Other Debt Description

Food*

Gas*

Cell Phone/Home Phone*

Utilities/Gas/Electric/Water*

Car Insurance*

Student Loans*

Other Loans*

Outstanding Loan Balances

Please type "0" if this debt doesn't apply

First Mortgage Balance*

Second Mortgage Balance*

Auto Loan Balance*

Credit Card Balance*

Other Debt Balances*

Checking and Savings Accounts

Please type "0" if this bank information doesn't apply

Bank 1 Name*

Bank 1 Balance*

Bank 1 Balance Date*

Bank 2 Name*

Bank 2 Balance*

Bank 2 Balance Date*

Bank 3 Name*

Bank 3 Balance*

Bank 3 Balance Date*

Payee 1

If your loan is approved, please indicate which bill(s) you would like paid with these loan funds. Please note there is a maximum of two creditors and the maximum total loan amount is $1,500. Please see Loan Application Instructions at www.feea.org/emergency for list of allowable expenses.

Loan Amount to be paid by FEEA to Payee 1*

Payee 1 Name*

Payee 1 Address*

Payee 1 City*

Payee 1 State

Payee 1 Zip*

Payee 1 Phone Number*

Payee 1 Account Number (if any)

Payee 2

Loan Amount to be paid by FEEA to Payee 2

Payee 2 Name

Payee 2 Address

Payee 2 City

Payee 2 State

Payee 2 Zip

Payee 2 Phone Number

Payee 2 Account Number (if any)

Required Attachments

Only Adobe Acrobat (.pdf) files allowed. Please attach only the document(s) requested on each line. Do not attach the same document more than once or on more than one line.

Most Recent SF-50 (Notification of Personnel Action)*

Add File...

Most Recent Employee Leave and Earnings Statements*

Add File...

Most Recent Spouse's Leave and Earnings Statements

Add File...

Evidence of Emergency (see Loan Application Instructions at www.feea.org/emergency for list of acceptable evidence)*

Add File...

Copy of bill(s) you are seeking assistance for*

Add File...

Copy of state-issued driver or non-driver ID*

Add File...

Credit Release Authorization (included in Loan Application Instructions available at www.feea.org/emergency)*

Add File...

Terms, Signatures and Verification

clear

Typed
Drawn

I agree to terms and services.

Signature *

Date *

Signature *

Date *

clear

Typed
Drawn

I agree to terms and services.

Signature *

Date *

Signature *

Date *

clear

Typed
Drawn

I agree to terms and services.

Signature *

Date *

Signature *

Date *

clear

Typed
Drawn

I agree to terms and services.

Signature *

Date *

Signature *

Date *

clear

Typed
Drawn

I agree to terms and services.

Signature *

Date *

Signature *

Date *

Captcha*