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FSG Bill Relief
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21
Questions
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1
Name
*
This field is required.
First Name
Last Name
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2
Phone Number
*
This field is required.
Please enter a valid phone number.
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Enter
3
Email
*
This field is required.
example@example.com
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4
Rent Or Mortgage
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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Enter
5
Upload Rent Or Mortgage Bill Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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6
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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7
Utilities
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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8
Upload Utility Bills Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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Enter
9
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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Submit
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Enter
10
Car Notes & Insurance
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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Submit
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Enter
11
Upload Car Notes & Insurance Bills Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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Next
Submit
Press
Enter
12
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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Submit
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Enter
13
Medicare | Medicaid | Prescriptions
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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Enter
14
Upload Medical Bills Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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Next
Submit
Press
Enter
15
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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Next
Submit
Press
Enter
16
Education
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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Next
Submit
Press
Enter
17
Upload Education Bills Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
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Next
Submit
Press
Enter
18
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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Next
Submit
Press
Enter
19
Childcare
*
This field is required.
If Yes, Then click Next to upload bill. | If No, Select No and Click Next.
YES
NO
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Next
Submit
Press
Enter
20
Upload Childcare Bills Here
If You Do Not Have A Bill, Click Next!
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
21
If You Do Not Have A Photo Copy Of Bill
Enter Bill Amount Needed.
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Next
Submit
Press
Enter
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