Personal Hardship Application
Applicant Information
Name of Applicant
*
Prefix
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
E-mail of Applicant
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What hardship are you facing?
*
Please provide a brief statement explaining your current hardship, including the specific challenges you are facing and the type of assistance you need.
*
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Do you have insurance that will help to cover your losses?
Yes
No
Are any of these Payment Deferments in process or completed.
*
Response
Rent or Mortgage Payment
Yes
No
Facing Foreclosure/Eviction
Yes
No
Facing Utilities Cut-Off
Yes
No
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Amount Requested and Documentation
Amount Requesting
*
How will you use the Funds
*
Rent/Lease
Utilities
Emergency Repairs
Other
Application of Funds – Required Documentation Please provide receipts and supporting documentation for all costs the requested funds will cover. The following documentation is required based on the type of assistance being requested: 1. Utilities Assistance – Copy of shut-off notice or documentation showing late/unpaid balances. 2. Rent/Lease Assistance – Copy of late notice or eviction notice from landlord/property manager. 3. Emergency Repairs – At least one estimate from a licensed contractor, including a detailed scope of work and pricing for the repairs. Incomplete applications or missing documentation may delay review and processing of your request.
*
Upload Documentation Files
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I attest that the information provided in this application herein are true and correct.
*
Yes
Signature
*
Submit my application
Submit my application
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