Personal Hardship Application
Applicant Information
Name of Applicant
*
Prefix
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail of Applicant
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How many people reside at the residence (including yourself)?
*
Rows
Response
Total in the Household
Under age 18
Over age 65
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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.
*
Do you have insurance that will help to cover your losses?
Yes
No
Are any of these Payment Deferments in process or completed.
*
Rows
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. 2. Rent/Lease Assistance – Copy or eviction notice or court proceeding 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. Please note all approved assistance will be paid directly to the creditor/landlord.
*
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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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