COVIDFRA myUH ID________________
2019-2020 CARES Act Grant / Cougar Emergency Fund Request
Last Name First Name MI
This form can be used to request assistance from either the 2019-2020 CARES Act Grant or the Cougar Emergency Fund for
expenses related to the disruption of campus operations due to coronavirus. Allowable expenses must be related to the student's
cost of attendance, and include items such as food, housing, course materials, technology, health care, and childcare. After completing
all appropriate sections of this form, submit the completed form with all required supporting documentation as
one PDF document to your myUH account. Directions to upload can be found at uh.edu/sfaupload. Please do not email this
document, as it is not secure.
STEP 1: Letter of Explanation
o Provide a detailed explanation supporting your COVID-19 request below. Please identify all allowable expenses pertaining to
your request as defined above. If you need additional space, please attach a separate typed, and signed statement. If you are a
dependent student, any attached additional statement must be signed by you and at least one parent. You must include a
timeline of events. List all specific dates (i.e. date of loss of job, date of separation, date of rehire, etc.).
STEP 2: Check the reason(s) for this request and attach the required documentation indicated below each option.
LOSS OF PARENT, STUDENT, OR SPOUSE INCOME (due to layoff, termination, or reduction of hours):
Please note, lost income cannot be funded with 2019-2020 CARES Act emergency grants, although it may be considered for
Cougar Emergency Fund grants.
o Submit documentation from former employer confirming loss of income, date of separation, and amount of severance pay.
o Submit copy of last pay stub from previous job showing year to date earnings.
o Submit copy of most recent pay stub from current job, if applicable.
o Submit a printout of the Texas (or applicable state) Workforce Commission Claim and Payment statement.
o If you are unable to provide these documents, please explain why:
DEATH OF PARENT OR SPOUSE:
o Submit copy of death certificate, obituary, or funeral pamphlet.
OTHER: ______________________________________________________________________________________
o Submit documentation identifying sources of income, how funds were spent, and the amount of any remaining funds.
o For medical expenses, submit bills showing what was paid out of pocket and not covered by insurance.
*Note: The FAFSA automatically considers 11% of income for medical expenses. Submitted medical expenses must exceed this allocation.
4434 University Drive, Houston, Texas 77204-2010 · Phone (713)743-1010, option 5 · Fax (713)743-9098
Email: [email protected] · www.uh.edu/financialaid
COVIDFRA myUH ID________________
STEP 3: Expenses
If you are submitting this request to cover expenses incurred related to the disruption of campus operations due to
coronavirus, please check the appropriate category below and indicate an amount. Please attach copies of each bill to this
form, as appropriate:
Category Amount Copy of Bill or Statement Attached?
Housing (i.e. rent, or mortgage) $ Yes No
Utilities: Water $ Yes No
Utilities: Gas $ Yes No
Utilities: Electricity $ Yes No
Utilities: Phone $ Yes No
Food (Estimate) $ Yes No
Childcare $ Yes No
Health care $ Yes No
Course materials $ Yes No
Technology $ Yes No
Other: $ Yes No
Other: $ Yes No
STEP 4: Requested Amount
Please indicate the total amount you are requesting in assistance: $ ___________________*
*Please note that this will not guarantee you will receive this amount. Determined amounts are based on funding limitations and funding availability.
STEP 5: Certification Statement: In order to submit your 2019-2020 CARES Act Grant/Cougar Emergency Fund
Request, you and a parent (if you are a dependent student) must agree to the terms listed. You, the student, must agree that
funds shall not be used for any purpose other than for the allowable expenses related to the disruption of campus
operations due to coronavirus as listed above.
Your signature on this document certifies all the information submitted for review is true and complete to the best of your
knowledge. You also certify you understand the Department of Education has the authority to verify and examine the
information reported on your application with other federal agencies, commissions, or departments with jurisdiction and
authority.
Student Signature: ______________________________ Phone or Email: ____________________________ Date: ___________
Parent Signature: ______________________________ Phone or Email: ____________________________ Date: ___________
Dependent Students Only
4434 University Drive, Houston, Texas 77204-2010 · Phone (713)743-1010, option 5 · Fax (713)743-9098
Email: [email protected] · www.uh.edu/financialaid
