Privacy notice

This form asks for sensitive personal information, including your date of birth. It is sent over a secure, encrypted connection to accounting@emmonak.com for processing this request. If you would prefer not to enter this information online, download the PDF version and mail the signed original to Emmonak Corporation, P.O. Box 49, Emmonak, AK 99581.

Fields marked * are required. If the Submit button appears to do nothing, please check that every required field, including all four acknowledgements at the bottom, is complete.

1 · Your information

Full legal name *

Shareholder enrollment number *🔒 SENSITIVE

Date of birth * (MM/DD/YYYY)🔒 SENSITIVE

Email *

Phone *

Mailing address *

2 · The emergency

What kind of emergency? *

Medical emergency

Death in immediate family

Disaster (fire, flood, severe storm)

Other emergency

Who is affected by this emergency? *

3 · Funds requested

How should the funds be paid? *

Cash or check to me

Direct payment to vendor (funeral home, medical provider, airline)

Airfare voucher

4 · Supporting documentation

Documentation status *

I will email supporting documentation to president@emmonak.com immediately

I will send documentation by mail within 7 days

I will bring documentation to the Corporation office in person

5 · Acknowledgements

I understand this is a once-per-fiscal-year (calendar year) shareholder benefit and that eligibility resets on January 1.

I understand payments may be taxable to me and reported on IRS Form 1099-MISC if cumulative annual payments to me are $600 or more.

I understand the decision of the President & CEO is final, and that approval is at the Corporation's sole discretion subject to Board-approved guidelines.

Emergency Funds Request

1 · Your information

2 · The emergency

3 · Funds requested

4 · Supporting documentation

5 · Acknowledgements