• Temporary Hardship Waiver Request

  • NOTICE: All waiver requests are subject to EMPOA board and Finance Committee approval. Information submitted via this form is strictly confidential and will only be reviewed by the EMPOA board, EMPOA Finance Committee, TN Comptroller auditors and/or IRS auditors. Submitted information must be securely retained only for governmental auditing purposes and will not be shared with any additional private organizations and/or entities otherwise. Approved hardship waivers are only applicable for 1 full fiscal year and must be reapplied for each successive year. Hardship waivers are established on a case by case basis. All decisions are at the discretion of the EMPOA board and Finance Committee.

  • Format: (000) 000-0000.
  • Do you currently reside full time inside of the EMPOA?*
  • Do you own or partially own multiple real estate properties?*
  • Have you recently applied for or have been granted "disability assistance"?*
  • Are you the primary care-giver for someone who has recently applied for or have been granted "disability assistance"?*
  • Are you currently employed?*
  • Have you or has someone in your care been recently diagnosed with any medical conditions which may jeopardize your ability to maintain gainful employment?*
  • Do you have any currently outstanding medical bills which exceed your financial capabilities?*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Should be Empty: