Toggle navigation
REQUEST FOR ASSISTANCE FORM
A CTDI employee may request financial assistance up to a maximum of $1,000 per year for himself/herself and/or his /her immediate family members who are suffering from cancer or other serious illnesses. Please submit your completed form to
CTDI_CARES@ctdi.com
CTDI CARES MISSION STATEMENT
Our mission is to provide funding and support to CTDI employees or their immediate family members who are afflicted or stricken with cancer or other serious illnesses. Our goal is to lessen the financial burdens and to help CTDI employees or theirimmediate family members confront the challenges of cancer or other serious illnesses with determination and hope.
EMPLOYEE INFORMATION
NAME:
MAILING ADDRESS:
CITY:
STATE:
ZIP:
BRANCH:
DEPARTMENT:
EMAIL:
HOME OR CELL NUMBER:
HOW DID YOU HEAR ABOUT CTDI CARES?
BENEFICIARY INFORMATION
RELATION TO EMPLOYEE (Leave Blank if Applying for Yourself):
ILLNESS:
AMOUNT REQUESTED:
DOES THE BENEFICIARY LIVE WITH YOU?
IF APPLYING FOR A CHILD, WHAT IS THEIR AGE?
Please be as detailed as possible with the reason for your request and what you will be using the funds for. Please note that, due to governmental regulations, we are unable to reimburse for medical expenses, co-pays or healthcare insurance premiums. Immediate family members are limited to an employee’s spouse, children (under the age of 18), dependent parents or children (over the age of 18) who live with and are solely financially supported by the employee.