WPH application

THE WHEELER W. PRICE MEMORIAL HUNT, INC.

The Wheeler W. Price Memorial Hunt, Inc., a 501c(3) entity, was created to honor the memory of Wheeler W. Price, who died January 15, 2014 as the result of Hodgkin's Lymphoma, a form of cancer. In February of 2014 friends of Wheeler organized a pheasant hunt for the benefit of Wheeler's children. The hunt was a huge success and the organizers decided to continue the hunt for the benefit of those persons and their families who are suffering as the result of cancer. As a result, The Wheeler W. Price Memorial Hunt, Inc., a 501c(3) entity was formed. It is governed by a Board of Directors (for a list of Board Members see below

If you or someone you know is suffering from cancer and he/she and their family is incurring extraordinary expenses, such as living expenses, travel expenses, etc., as a result thereof, you may complete the Application below and submit to the address below or email to mprice@servisfirstbank.com. Your Application will be reviewed by the Board of Directors and you will be advised as to the results.

Wheeler was born October 28, 1979 in Dothan, Alabama where he lived his entire life.

He was a 1998 graduate of Northview High School and a 2003 graduate of Auburn University where he was a member of Sigma Alpha Epsilon Fraternity. He was employed in management with Cox Pools and later in his career with Bobcat of the Wiregrass.

Wheeler was a member of First United Methodist Church. He enjoyed fishing, hunting, and Auburn Football. He especially enjoyed spending time with his children and family. He is the proud father of Wheeler Whitlow Price, Jr., "Whit", who was born in May of 2009, and Elizabeth Warner Price, "Libby", who joined the family in March of 2011.

Wheeler was diagnosed with cancer October 22nd, 2011, at the age of 32. As a result, Wheeler received chemotherapy treatments in Dothan, Alabama and Houston, Texas. Wheeler, Melissa and family moved to Houston, Texas on two different occasions so that Wheeler could receive treatment for the cancer that eventually resulted in his death. As a result, Wheeler and his family realize the financial hardship that results from living away from home, without employment, and enduring a disease such as cancer.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Phone Number
Additional Contact Number
SSN
List other members of your household, including children. Please provide the name, relationship, age, and employer of each household member:
REQUEST
Amount of Request
Date of Application

MonthDayYear
Date
Name, Address, and Phone Number of person completing this form:
Please attach your Personal Statement. Tell us how the funds will be used, and explain the circumstances that have prompted your need of assistance and proposed resolution.

Please attach appropriate bids/estimates/bills directly relating to your request.
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Employment Information
Is the applicant currently employed

YesNO
Is the applicants spouse currently employed?

YesNONot Applicable
If you answered no, to any of the above questions, list the last employer and employments dates for both the applicant and the applicants spouse. Please provide an explanation.
Gross MONTHLY earnings (include all employed members of the household) Please attach 3 months proof of income.

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Please list the last two (2) Employers of the Applicant and provide the following: Employer, Supervisor's Name, Address, Phone Number, Dates of Employment, Salary / Wage
Please list the last two (2) Employers of the Applicant's Spouse and provide the following: Employer, Supervisor's Name, Address, Phone Number, Dates of Employment, Salary / Wage
Please list the last two (2) Employers of other employed members of the Applicant's Household and provide the following: Employer, Supervisor's Name, Address, Phone Number, Dates of Employment, Salary / Wage
Monthly Expenses

monthly expenses must be accompanied with documentation
Housing
Monthly Mortgage or rent payment:
Monthly Food Expenses:
Real Estate Taxes
Utilities
Monthly Electricity Bill:
Monthly Gas Bill:
Monthly Telephone / Cell Phone Bill:
Monthly Water / Sewer / Trash Bill:
Monthly Cable / Satellite / TV BILL:
Monthly Internet Bill:
Other Monthly Utility Expenses:
Transportation:
Monthly Automobile Payments:
Average Monthly Gasoline Costs:
Car Tag / Tax:
Insurance
Monthly Medical / Dental / Vision Payment:
Monthly Life Insurance / Burial Policy Payments:
Monthly Automobile Insurance:
Monthly Homeowners / Rental Insurance:
Credit Card Charge Accounts

Please list each account and specify name, balance, and monthly payment
Name:   Type a label   Balance:
Name:   Type a label   Balance:
Name:   Type a label   Balance:
Name:   Type a label   Balance:
Name:   Type a label   Balance:
Loan Payments

Please List each existing loan along with the balance and monthly payment
Name:   Type a label   Balance:      Payment:
Name:   Type a label   Balance:      Payment:
Name:   Type a label   Balance:      Payment:
Name:   Type a label   Balance:      Payment:
Other Expenses:
Please list any other expenses that are not listed above. Include the name and the monthly amount due and/or balance.
$
Total Monthly Expenses
What is the total amount of your monthly expenses:
Please upload all documentation related to your monthly expenses

please include all bills, statements, and receipts
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Monthly Income
Total Gross Earnings for Household
Bonus, Tips, & Commissions
Social Security Benefits
Farm Income
Dividends & Interest
Real Estate Income
Alimony
Child Support
Food Stamps
Other
Other
Other
Total Monthly Income
Liabilities
Notes & Payable Mortgages #1
Lender Name:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Notes and Payable Mortgages #2
Lender Name:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Notes and Payable Mortgages #3
Lender Name:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Total Notes and Mortgages
Other Debt

Taxes, Bills, Miscellaneous - include address. An attached list can be included.
Debt #1:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Debt #2:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Debt #3:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Debt #4:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Debt #5:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Debt #6:
Address:   Street Address   Address Line 2   City   State   Zip
Phone Number:   Area Code   Phone Number
Balance:
Monthly Payment:
Total Liabilities
Please upload all documentation associated with Liabilities

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The information contained in this statement is for the purpose of obtaining funding from The Wheeler W. Price Memorial Hunt, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used to consider the request for funding, and each undersigned represents and warrants that the information provided is true and complete and that The Wheeler W. Price Memorial Hunt, Inc., may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Wheeler W. Price Memorial Hunt, Inc. is hereby authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Information provided herein shall be deemed confidential.
Signature of Applicant

Clear
Date

MonthDayYear
Date
Signature of Spouse/Co Applicant

Clear
Date

MonthDayYear
Date
The Wheeler W. Price Memorial Hunt, Inc. is hereby authorized to utilize applicants name/organization for promotional or communication purposes (i.e. annual reports, news/press releases, brochures, etc)
Signature of Applicant

Clear
Date

MonthDayYear
Date
Should be Empty:

REQUEST

Employment Information

Monthly Expenses

Housing

Utilities

Transportation:

Insurance

Credit Card Charge Accounts

Loan Payments

Other Expenses:

Total Monthly Expenses

Monthly Income

Liabilities

Other Debt