ACE Assistance Program Application

ACE Assistance Application

This form is to be completed by the ACEBSA member and/or responsible party. The information requested below will provide a basis for establishing eligibility for financial assistance. The committee reserves the right to verify all information provided.
Applicant Information
Applicant Name

First NameMiddle NameLast Name
Total Number in Family
Last Four Digits of SSN
Case Number
Monthly Income
Salary Gross Amount
Salary Net Amount
Spouse Salary Gross Amount
Spouse Salary Net Amount
Monthly Net Income
Other Gross Amount
(i.e. pensions, disability, interest, alimony, etc.)
Other Net Amount
(i.e. pensions, disability, interest, alimony, etc.)
Rental Gross Income
Rental Net Income
Other Monthly Gross Income
(i.e. unemployment benefits, workers compensation)
Other Monthly Net Income
(i.e. unemployment benefits, workers compensation)
Total Gross Amount
Total Net Amount
Payroll Deductions
Car Payments
Savings Plans/Bonds/Credit Unions
Total Payroll Deductions
Liquid Assets
Checking Account Number
Checking Amount
Bank Name
Bank Branch
Savings Account Number
Savings Amount
Savings Account Number
Savings Amount
Savings Bank Name
Savings Bank Branch
Credit Union Name
Total Amount in Checking, Savings, and Credit Union Accounts
Cash On Hand
Total Liquid Assets
Expenses
House Payment To Whom Paid
House Monthly Payment
House Amount Past Due
House Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Water/Electric/Gas/Phone Monthly Payment
Water/Electric/Gas/Phone Amount Past Due
Transportation Monthly Payment
Transportation Amount Past Due
Food Monthly Payment
Food Amount Past Due
Car Year & Make
Car Monthly Payment
Car Amount Past Due
Car Year & Make
Car Monthly Payment
Car Amount Past Due
Life Insurance Company
Life Insurance Face Value
Life Insurance Monthly Payment
Life Insurance Amount Past Due
Total Medical/Dental Monthly Payment
If any, list below to whom payments are made.
Total Medical/Dental Amount Past Due
Alimony/Child Support Monthly Payment
If any, list below to whom payments are made.
Alimony/Child Support Amount Past Due
Day Care Monthly Payment
For working parents.
Day Care Amount Past Due
Health Insurance Premiums Monthly Payment
Other than those deducted from wages.
Health Insurance Premiums Amount Past Due

Department Store & Charge Account and Loans

Rows	Name	Monthly Payment	Amount Past Due
1
2
3
4

Master Card Number
Bank & Location
Amount Payment
Limit
Amount Due
Visa Card Number
Bank & Location
Amount Payment
Limit
Amount Due
Total Expenses Monthly Payment
Total Expenses Amount Past Due
Please upload supporting documents for all listed expenses.

Note: Failure to include all supporting documents for expenses may result in rejection or delay of application.
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Miscellaneous
Market Value of House
Equity in House
Other Property Value (Specify)
Address of Other Property
Did you attempt to obtain a credit union loan for this emergency?
If yes, please provide the loan amount.
Are you filling out this application due to your own illness/injury?
If yes, please describe your illness/injury.
If yes, please also attach the doctor's report on your current condition.

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Are you currently hospitalized?
If yes, please indicate date admitted and date discharged.
If yes, have you applied for Workers Compensation?
If yes, what is the current status?
Are you filling out this application due to the illness/injury of a family member?
If yes, please provide the following information.
Family Member's Name

First NameLast Name
Age
Relationship
Was the family member hospitalized?
If yes, how long were they hospitalized?
Was the family member employed?
If yes, please attach their last paycheck stub.

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I certify the information hereon to be accurate and complete. I understand that ACEBSA reserves the right to verify all the information supplied.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

ACE Assistance Application

Applicant Information

Monthly Income

Payroll Deductions

Liquid Assets

Expenses

Miscellaneous

If yes, please provide the following information.