Employee EFAP Agreement

EMPLOYEE EFAP AGREEMENT

Personal Information

Position Information

Reporting Manager:    Start Date:

Salary/Rate: $    Employment Status: Full-time Part-time Contractor

EFAP Program Request

Purpose of Assistance (select all that apply):
Counseling / Mental Health Short-term Financial Assistance Legal Consultation Dependent Care Support Emergency Travel Other:

Eligibility and Participation Terms

The Employee Family Assistance Program (EFAP) provides limited, discretionary assistance to eligible employees for personal and family emergencies. Participation in EFAP is conditioned upon continued employment, verification of eligibility, and compliance with program rules. Receipt of EFAP assistance does not alter at-will employment status.

Eligibility Criteria: Employee must be an active employee at the time of application and at time assistance is provided. Eligibility determinations require submission of documentation sufficient to substantiate need, as requested by the program administrator.

Assistance Limits: EFAP assistance is limited per incident and per rolling twelve-month period. Approval is discretionary and subject to available program funds. Any financial assistance granted is a one-time or limited-term payment as expressly authorized in writing by an authorized representative.

Confidentiality and Data Use

All information supplied in support of an EFAP request will be treated as confidential to the extent permitted by law. By submitting this application, Employee authorizes the Employer and its designated program administrator to access, use, and disclose necessary information to verify eligibility, process the request, and administer the assistance. Such disclosures will be limited to the minimum information necessary to effectuate review and payment.

Repayment and Recovery

If EFAP assistance is provided as a loan or is otherwise payable by Employee, Employee agrees that Employer may recover amounts owed from future pay, subject to applicable wage and hour laws, or by other lawful collection means. Employee will be provided written notice of repayment terms prior to disbursement.

Tax Treatment

Any financial assistance provided may be reportable for tax purposes in accordance with applicable law. Employer will report benefits and withhold taxes as required by law; Employee bears responsibility for tax consequences. Employer does not provide tax advice.

Documentation and Verification

Employee must provide truthful documentation of the circumstances and any expenses for which assistance is sought. Fraudulent or materially misleading statements or submission of false documentation will result in denial, recovery of funds, disciplinary action up to and including termination, and possible civil or criminal liability.

Appeal and Termination

Denials of EFAP assistance may be appealed in writing within ten (10) business days of notice. Employer reserves the right to modify, suspend, or terminate the EFAP and services at any time, with or without notice, except where prohibited by law.

Employment History (Most recent first)

Education

Graduation Date:

References (Professional)

Legal Disclosures and Authorizations

At-Will Employment: Employee acknowledges and agrees that employment with the Employer is at-will and may be terminated by either party at any time, with or without cause, except as otherwise provided in a written agreement signed by an authorized representative of the Employer.

Equal Opportunity: Employer is an equal opportunity employer. Decisions related to EFAP assistance will not unlawfully discriminate on the basis of protected characteristics.

Authorization to Verify: Employee authorizes Employer and its agents to contact prior employers, references, healthcare providers (as necessary for verification of medical necessity), and other sources to verify the information provided. Employee expressly authorizes release of information to the program administrator and Employer for the purposes of evaluating and administering this EFAP request.

Background Check Consent: Employee consents to any background, employment verification, and reference checks reasonably necessary for processing this request and understanding eligibility for assistance, including credit checks where applicable to financial assistance evaluation.

Applicant Certification

I certify that all information provided in this Employee EFAP Agreement and accompanying documentation is true, complete, and submitted in good faith. I understand that providing false or misleading information may result in denial of assistance, disciplinary action up to and including termination, and legal action to recover funds. I agree to comply with all program procedures and provide additional documentation upon request.

Dispute Resolution and Governing Law

Any dispute arising out of or related to this Agreement shall first be submitted to the Employer's internal appeal process. If unresolved, disputes shall be resolved by binding arbitration in accordance with the rules selected by the Employer, except where prohibited by applicable law. This Agreement is governed by the laws of the state where the Employer maintains its principal place of business, without regard to conflict-of-law principles.

Acknowledgment and Consent

By signing below, Employee confirms that Employee has read and understands the terms of this EFAP Agreement, consents to the release and verification of information as described, and agrees to the conditions governing participation in the EFAP.

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