Application for Financial Hardship Waiver

Application for Financial Hardship Waiver

S.S.E.S.A. - Perry Area Fire Rescue
Applicant Information:
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Call Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Information:

Enter Insurance Information below, if we have not billed an active policy on your behalf.
Insurance Company Name:
Policy / Member / Subscriber ID
Financial Hardship Information:

Enter the requested information below. This will be used to determine your eligibility for assistance.
Employment Status*

Employed - Full TimeEmployed - Part TimeUnemployedRetiredOther
Reason for Financial Hardship*

UnemploymentHigh Medical ExpensesDecrease in Work HoursOther
Other
If you selected Other above, please explain.
Gross Monthly Household Income*
Number of Dependents*

Monthly Expenses: Enter 0.00 in any expense that does not apply.*

Rows	Amount Monthly
Rent / Mortgage
Transportation
Utilities
Food
Medical Expenses
Other Contributing Expenses

Supporting Documentation:

Failure to provide the necessary documentation, will result in this applications denial.
* Proof of Income / Unemployment Payments

* Documentation of Medical Expenses

* Proof of Rent / Mortgage Amount

* Other supporting documentation that substantiates your hardship claim
File Upload*

Attach supporting documentation here.
Cancelof
Certification:

By signing below, I certify that the information provided in this Application for Financial Hardship Waiver is true and accurate to the best of my knowledge. I understand that providing false or misleading information may result in a denial of financial hardship assistance.
Signature*

Clear
Should be Empty:

Applicant Information: