Confidential Application

Assistance for the NMAR family when they encounter financial hardships beyond their control.

Any member or past member or staff of the Association is eligible to submit an application or have an application submitted for him or herself or his or her immediate family. Immediate family shall be defined as a spouse, domestic partner, sibling, or child.

Please answer all questions thoroughly

1. Applicant's Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. Member NRDS # or relationship to NMAR member

3. Independent Contractor or Employee of:

4. Home Phone

Format: (000) 000-0000.

5. Office Phone

Format: (000) 000-0000.

If you are other than applicant and are assisting with this application:

6. Name

7. Home Phone

Format: (000) 000-0000.

8. Office Phone

Format: (000) 000-0000.

Applications for assistance must be for a specific need that would insure a specific benefit to the member or family member due to prolonged illness, catastrophic occurrence or accident -- for example, one month's health insurance premium to maintain insurance; one month's house note to prevent foreclosure due to prolonged illness; burial expenses when there are limited or no funds in the household; payment toward the purchase of special prosthesis, wheelchair, oxygen equipment, or organ transplant not fully covered by the member's insurance. Awards shall be issued directly to a vendor. Attach copies of appropriate invoices or statements. Assistance may be provided in grant or loan form.

All requests for Benevolent Fund grants are entirely confidential. Directors, who review requests, do NOT receive name or address of person making request. Requests will not be reviewed by the Fund Directors until complete. Please be as specific as possible. Application will be reviewed by staff to determine that criteria outlined in Benevolent Fund Policies and Procedures have been met before it is distributed to Directors.

B. Describe the situation or condition creating the need to request an award. Be specific. For example, if illness or injury is involved, define the illness, dates hospitalized, doctor's name, dates off work, date due back, etc. Attach supporting documentation, i.e. doctor's letter.

C. What are you requesting be paid by the Benevolent Fund?

D. What other sources of relief have been initiated? (i.e. lending agencies, credit union, family/friends, community service agencies, legal assistance, disability assistance, credit counseling, etc

E. Define your financial status

1. Total Assets $

2. Total Liabilities $

3. Total Monthly Income

4. Total Monthly Expenses $

F. List all the persons living with you: (Name/Relationship/In School(Y|N|Grade)/Working/Where

G. Recommendations - Attach any recommendations regarding your application

H. CERTIFICATION

I certify that the above information is true to the best of my knowledge and I understand that any misrepresentation or willful omission of facts shall be cause for corrective action up to and including repayment of funds advanced. I authorize verification as deemed necessary and agree to help the NMAR Benevolent Fund to obtain these verifications if requested.

(Signature)

(Date)

Date

(Signature)

(Date)

Date

Please list vendors you are requesting be paid by grant funds and amount due. Copies of actual invoices will be requested if grant/loan is approved.

Vendor

Amount Due

Address

Account Number

Vendor

Amount Due

Address

Account Number

Vendor

Amount Due

Address

Account Number

Vendor

Amount Due

Address

Account Number

(Add additional pages as necessary. The Benevolent Fund Directors reserve the right to make decisions based on funds available.)

By clicking "Submit" your application and supporting materials will be sent directly to NMAR Staff for processing.

Upon receipt and after administrative review, application will be distributed to the Benevolent Fund Board of Directors for their review. Applicant will be notified of decision of the Directors promptly. All applications and inquiries are confidential.

If you have any questions, please call Ambyrly Maestas at 505-467-6307or e-mail Ambyrly@nmrealtor.com

Confidential Application

PLEASE NOTE:

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