Financial Hardship Assistance Request
NOTICE: All form requests are subject to EMPOA board approval. Information submitted via this form is strictly confidential and will only be reviewed by the EMPOA board, EMPOA Financing 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. Payment arraignments are established on a case by case basis. All decisions are at the discretion of the EMPOA board.
Name
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First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
EMPOA Address
*
Street Address
Lot & Section Number
City
State / Province
Postal / Zip Code
Is this currently your full time residence?
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Yes
No
Do you own or partially own any other real estate properties?
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Yes
No
Have you recently applied for or have been granted "disability assistance"?
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Yes
No
Are you the primary care-giver for someone who has recently applied for or have been granted "disability assistance"?
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Yes
No
Are you currently employed?
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Yes
No
Have you or has someone in your care been recently diagnosed with any medical conditions which may jeopardize your ability to maintain gainful employment?
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Yes
No
If so, please elaborate
Do you have any currently outstanding medical bills which exceed your financial capabilities?
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Yes
No
If so, please upload copies of these bills
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Please list the minimum monthly payment amount in which you realistically believe you can afford.
*
Please upload your most recent tax return
*
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Please list any other pertinent information which should be considered in this matter.
By signing below, you confirm that the information submitted is accurate to the best of your knowledge. To edit or redact any submitted information, please contact the Finance Committee at finance@englishmountainpoa.com
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