APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA
|
|
- Ethelbert Ball
- 6 years ago
- Views:
Transcription
1 APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA PROGRAM OBJECTIVE: HOPE stands for Helping Our Peers in Emergency. It is a crisis fund supported by Scripps employees for Scripps employees. It is our way of reaching out to help someone in need. ELIGIBILITY CRITERIA: (Must meet all criteria to qualify) Full-time, Part-time, or Casual employee Employee must have worked 1,000 hours or more in the previous year Employee has been employed with Scripps no less than 180 days (approx. 6 months) Employee has not received a formal corrective action or written warning within the last 12 months No employee will be eligible for aid more than two times during his or her employment with Scripps Health PTO hardship hours, if available, will be utilized prior to HOPE Fund approval QUALIFYING EVENTS: (Per the IRS Safe Harbor guidelines) Funeral expenses of parents, spouse, children or dependents Expenses for medical care previously incurred by the employee, the employee s spouse or any dependents of the employee or necessary for these persons to obtain medical care Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) Payments necessary to prevent the eviction of the employee from the employee s principal residence or foreclosure on the mortgage on the residence Certain expenses relating to the repair of damage to the employee s principal residence due to catastrophic casualty loss Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of postsecondary education for the employee, or the employee s spouse, children, or dependents APPLICATION PROCESS: Complete the HOPE Fund application in full, include all supporting documentation, and submit to your site Human Resources Department The site HOPE committee will review the request and determine eligibility and request more information, if necessary. Based on the review and findings of the committee, they will either approve or deny the request If the site committee approves: The request is submitted to payroll for the initial $ The request is then forwarded to the system-wide HOPE Fund committee for further review of the remaining amount requested If the site committee denies: A site Human Resources representative will contact the employee with an explanation for the denial Employee provides details of hardship as well as financial plan for the future Award Amounts: Individual award amounts will vary, but are not to exceed $2, $ may be awarded at the site level, but requires approval All requests, regardless of amount, require supporting hardship documentation
2 IMPORTANT: Before turning in your application please review, complete, and sign the bottom of the checklist below. This form must be completed in full. By checking off the following information, you are confirming you meet the IRS Safe Harbor guidelines, qualify to receive the HOPE fund, and have provided the appropriate documentation to substantiate the request. QUALIFYING EVENTS: (Per the IRS Safe Harbor guidelines) (Please check all that apply) Funeral expenses of parents, spouse, children or dependents Expenses for medical care previously incurred by the employee, the employee s spouse or any dependents of the employee or necessary for these persons to obtain medical care Costs directly related to the purchase of a principal residence for the employee (excluding mortgage payments) Payments necessary to prevent the eviction of the employee from the employee s principal residence or foreclosure on the mortgage on the residence Certain expenses relating to the repair of damage to the employee s principal residence due to catastrophic casualty loss Payment of tuition, related educational fees, and room and board expenses, for the next 12 months of postsecondary education for the employee, or the employee s spouse, children, or dependents COMPLETING THE APPLICATION: Before submitting your application to Human Resources for processing, please remember to: Complete the application in its entirety Designate which IRS Safe Harbor guidelines the hardship falls under Provide documentation of proof of hardship Provide all necessary bank statements and pay stubs as required Provide details of the hardship as well as financial plan for the future SIGNATURE: DATE: By signing this application I am confirming I qualify to request HOPE Fund assistance. I have included all documentation requested and completed the application fully.
3 PLEASE PRINT OR TYPE APPLICATION. So that we can process your request as quickly as possible, please complete everything on this form. This information will be given to a member of the HOPE Fund team. You will be contacted soon for more information. The information you provide will be kept confidential. It will only be reviewed by those necessary to your application process. NAME: Last First Middle Int. EMPLOYEE ID #: SOCIAL SECURITY #: HOME ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL PHONE: WORK LOCATION: DEPT: DATE OF HIRE: WORK PHONE: JOB TITLE: NUMBER OF YEARS OF SERVICE AT SCRIPPS HEALTH: CURRENT STATUS: FULL-TIME PART-TIME CASUAL TOTAL AMOUNT REQUESTED: $ AND / OR Hours of PTO DATE NEEDED: If your request is granted, do you wish to: Have your check mailed (address) Pick up check I authorize Human Resources to verify the information provided on this form. I also authorize Human Resources to gather any additional information needed by the committee to process this request. I hereby acknowledge that the attached information is correct. SIGNATURE: Date: Request For Assistance Application Rev. 1/2010 1
4 PLEASE PRINT OR TYPE APPLICATION. The following information will be reviewed by the HOPE Fund Site and/or System Committee to determine financial eligibility. The information is strictly confidential. Therefore, DO NOT list your name on pages 3 and 4. Your file will be assigned an application number for accounting purposes only. Have you received HOPE Fund or Employee Emergency Trust Fund grants previously? YES NO If yes, amount: $ Date received: Reason: Describe the nature of your hardship. Explain what led you to your current financial situation. If your request for assistance is approved, what are your plans going forward to reconcile the hardship and prepare for the future? Please attach copies of itemized bank statement and priority bills you wish to be considered Request For Assistance Application Rev. 1/2010 2
5 Please deliver completed application to Human Resources. Please fill out as completely as possible. If supporting documents are attached for those areas marked with an asterisk*, your application may be processed more quickly. DEPENDANTS (DO NOT LIST NAMES) Relationship Age Relationship Age MONTHLY INCOME AMOUNT * Net (take home pay, provide previous 2 paystubs) $ * Workers Comp $ * State / Long Term Disability $ * Unemployment Insurance $ * Spouses Income (Include unemployment / disability / previous 2 paystubs) $ Other Sources of Income * Dependant s Income $ * Child Support $ * Alimony $ * Social Security $ * Rental Property $ * Stocks / Bonds / Dividends $ Assets Checking Acct(s) # $ Savings Acct(s) # $ Credit Union # $ Miscellaneous $ TOTAL INCOME $ MONTHLY EXPENDITURES AMOUNT Rent / Mortgage $ Child Care $ Automobile Payments $ Food $ Gas / Electric / Phone $ Water / Trash / Sewer $ Gasoline (Auto) $ Insurance Policies Life (Premium) $ Home Owners / Auto $ Medical / Dental $ Other Expenditures Loan Payments $ Charge Cards $ Medical / Dental Bills $ Miscellaneous $ TOTAL EXPENSES $ Request For Assistance Application Rev. 1/2010 3
6 *MANDATORY: Please submit itemized bank statement along with last 2 pay stubs. THIS SECTION TO BE COMPLETED BY THE SITE COMMITTEE: DATE APPLICATION RECEIVED: DATE TO SITE HOPE REVIEW COMMITTEE: DATE TO SYSTEM HOPE REVIEW COMMITTEE: RECOMMENDED SIGNED: DENIED SIGNED: INITIAL AMOUNT RECOMMENDED: $ ADDITIONAL FUNDS RECOMMENDED? YES NO COMMENTS: CONFIDENTIAL (HUMAN RESOURCES ONLY): CHECK WRITTEN TO: CHECK NO: AMOUNT: $ DATE: NOTIFICATION GTO EMPLOYEE DATE: PHONE: EMPLOYEE WISHES CHECK TO BE: Mailed: (Address) Picked Up: (Date and Time, if applicable) Request For Assistance Application Rev. 1/2010 4
APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA
APPLICATION FOR HOPE FUND ASSISTANCE PROGRAM GUIDELINES AND CRITERIA PROGRAM OBJECTIVE: HOPE stands for Helping Our Peers in Emergency. It is a crisis fund supported by Scripps employees for Scripps employees.
More informationUNFORSEEABLE EMERGENCY WITHDRAWAL. Part 1 - INSTRUCTIONS DEFERRED COMPENSATION PLAN
SUFFOLK COUNTY PUBLIC EMPLOYEES DEFERRED COMPENSATION PLAN WWW.SCDEFERREDCOMP.ORG UNFORSEEABLE EMERGENCY WITHDRAWAL Part 1 - INSTRUCTIONS IMPORTANT: Deferred Compensation Plan assets are your final resort!
More informationCITY OF DALLAS 457 DEFERRED COMPENSATION PLAN IMPORTANT NOTICE TO APPLICANTS
CITY OF DALLAS 457 DEFERRED COMPENSATION PLAN IMPORTANT NOTICE TO APPLICANTS The Internal Revenue Code permits 457 Plan participants to withdraw funds from their account, as a source of last resort, to
More informationCOOKSON HILLS ELECTRIC FOUNDATION, INC INDIVIDUAL APPLICATION E. Main - PO Box 539 Stigler, OK 74462
COOKSON HILLS ELECTRIC FOUNDATION, INC INDIVIDUAL APPLICATION 1002 E. Main - PO Box 539 Stigler, OK 74462 1800 KOA/Power Drive- PO Box 587 Sallisaw, OK 74955 Dear Applicant: Application Deadline Meeting
More informationIn order to process this application, we require:
Keck Medical Center of USC (KMC), which includes Keck Hospital of USC, USC Norris Cancer Hospital, and Verdugo Hills Hospital (VHH), is dedicated to providing quality health care to our patients. We realize
More informationYMCA of Greenwich Scholarship Application
YMCA of Greenwich Scholarship Application The YMCA of Greenwich enriches the community by promoting positive values through programs that build healthy kids and strong families. Please take your time completing
More informationName: (Last) (First) (Middle) Address: (Number and Street) (City) (State) (Zip) Most recent employer: Name: (Last) (First) (Middle)
INSTRUCTIONS: 1. Do not remove any pages from this application. The application must be returned to the Fund office in its entirety for it to be valid. 2. Carefully read this application in its entirety
More informationIn order to process this application we require:
Keck Medical Center of USC (KMC), which includes Keck Hospital of USC, USC Norris Cancer Hospital, and Verdugo Hills Hospital (VHH), is dedicated to providing quality health care to our patients. We realize
More informationRENTAL APPLICATION AGREEMENT
RENTAL APPLICATION AGREEMENT Envision Property Management Services LLC understands that moving to a new home can be both exciting and stressful. Our mission is to make this process as smooth and stress
More informationCHOPTANK ELECTRIC TRUST, INC.
CHOPTANK ELECTRIC TRUST, INC. P.O. Box 426, Denton MD 21629 1-877-892-0001, ext. 7733 APPLICATION FOR INDIVIDUAL AND/OR FAMILY Incomplete applications will automatically be denied assistance. Please fill
More informationInstructions for Completing the Short Sale Package. Send Ocwen the completed package and supporting documentation
Instructions for Completing the Short Sale Package Step 1 Complete all the enclosed attachments Exhibit G Borrowers Response package Step 2 Send Ocwen the completed package and supporting documentation
More informationApplication for Individual or Family
PLEASE READ COVER SHEET ENTIRELY Application for Individual or Family How can an individual or family apply for funding? Applications may be obtained by mail, website, or at one of our local offices and
More information2017 Income Tax Data-Itemizer
Documents Used to Verify Primary Taxpayer Identity: (select one) Driver's License (complete detail below) State issued identification card (complete detail below) Passport IDENTITY VERIFICATION WORKSHEET
More informationAPPLICATION AGREEMENT
APPLICATION AGREEMENT APPLICATION FEE IS NON-REFUNDABLE PLEASE FILL OUT THIS FORM COMPLETELY. APPLICATION FEE = $65.00 PER ADULT ($120.00 Joint). Application Fee is to be in the form of a Money Order REQUIRED
More informationVentura County 401(k) Shared Savings Plan Safe Harbor Hardship Withdrawal
Ventura County 401(k) Shared Savings Plan Safe Harbor Hardship Withdrawal The Internal Revenue Service follows very stringent rules for this type of withdrawal and will examine it very closely if the Plan
More informationFINANCIAL ASSISTANCE APPLICATION: COVER LETTER
FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order
More informationTax Intake Form Intake Pg 1 of 7 (or )
2013-2014 Tax Intake Form Intake Pg 1 of 7 (or ) FILING STATUS Single Married Filing Joint Married Filing Single Head of Household Qualifying Widower ADDRESS Street & Apt. No. City State & Zip County School
More informationHealthSource Saginaw, Inc. ADMINISTRATIVE MANUAL FINANCIAL ASSISTANCE A-090
HealthSource Saginaw, Inc. ADMINISTRATIVE MANUAL FINANCIAL ASSISTANCE A-090 POLICY: PURPOSE: PROCEDURE: Healthsource Saginaw will grant financial assistance to patients/residents who cannot pay for services
More informationFINANCIAL ASSISTANCE PROGRAM
Financial Assistance Application FINANCIAL ASSISTANCE PROGRAM As part of our mission, Benefis Health System (including Benefis Hospitals in Great Falls and Benefis Teton Medical Center in Choteau) is committed
More informationInstructions - financial assistance application
Instructions - financial assistance application Encompass Health Rehabilitation Hospital of Altoona 2005 Valley View Boulevard Altoona, PA 16602 814.944.3535 encompasshealth.com/altoonarehab Section A
More information807 Collinsworth Road Palmetto, GA , FAX
Coweta-Fayette Trust, Inc. 807 Collinsworth Road Palmetto, GA 30268 770-502-0226, FAX 770-251-9788 Incomplete applications will not be considered. To be complete, all 5 pages of this application must be
More information1040 US Tax Organizer
CLIENT INFORMATION First name and initial..... Title/suffix............... Occupation.............. 1=blind.................. Home phone............. Work phone............. Work extension.......... Cell
More informationGENERAL INFORMATION... 2 PLAN CONTRIBUTIONS... 2 PLAN DISTRIBUTIONS... 3 PLAN LOANS... 4 ENROLLMENTS... 4 PLAN YEAR-END COMPLIANCE TESTING...
PLAN SPONSOR S GUIDE GENERAL INFORMATION... 2 PLAN CONTRIBUTIONS... 2 PLAN DISTRIBUTIONS... 3 PLAN LOANS... 4 ENROLLMENTS... 4 PLAN YEAR-END COMPLIANCE TESTING... 5 FORM 5500... 6 DATES TO REMEMBER...
More information***Please keep this page for your records***
HARDSHIP CHECKLIST Please use this checklist to ensure that you have completely and accurately filled out the application. All documentation will be reviewed and does not guarantee the approval of your
More informationFINANCIAL STATEMENT FOR MORTGAGE AFFORDABILITY REVIEW
FINANCIAL STATEMENT FOR MORTGAGE AFFORDABILITY REVIEW PLEASE CALL 1-800-822-7375 IF YOU NEED ASSISTANCE COMPLETING THIS FORM. FAX COMPLETED, SIGNED, AND DATED FORM AND ATTACHMENTS TO: (717) 780-3804 OR
More informationLocal Relief Application
Local Relief Application Form 101-A This document is provided to offer general guidelines for providing financial relief to those in need. Generally speaking, an applicant s expenses must exceed their
More informationStudent/Spouse Special Condition Request
2018-2019 Student/Spouse Special Condition Request To submit the completed form: In person: MT One Stop, Student Services and Admissions Center (SSAC) Mail: MTSU, MT One Stop, SSAC Room 260, 1301 East
More information1040 US Tax Organizer
1040 US Bogush & Grady, CPA's LLP 48 West Market Street Tax Return Appointment Date: Time: Location: Telephone Rhinebeck, number: NY 12572-1403 Fax number: 8458764911 E-mail address: jgrady@bogushgradycpas.com
More informationCENTRAL LABORERS ANNUITY FUND
CENTRAL LABORERS ANNUITY FUND PO Box 1267, Jacksonville, IL 62651-1267 Phone 217-479-3600 or 800-252-6571 APPLICATION FOR HARDSHIP DISTRIBUTION The Central Laborers Annuity Fund ( Fund ) was created and
More informationHOMEOWNER WELCOME PACKAGE. Short Sale Frequently Asked Questions
HOMEOWNER WELCOME PACKAGE Welcome to LA City Short Sales! We understand that this can be a challenging and stressful time in your life and our goal is to make the short sale process as easy as possible
More informationOWNER OCCUPANT APPLICATION
ERIE REDEVELOPMENT AUTHORITY APPLICATION FOR RESIDENTIAL CDBG/HOME PROGRAM Updated November 2017 OWNER OCCUPANT APPLICATION IMPORTANT: COMPLETE ENTIRE FORM TO AVOID PROCESSING DELAYS OR DENIAL OF APPLICATION
More informationHRSA-ILA Annuity & Savings Plan Participant Hardship Statement
Submit this form to HRSA-ILA. HRSA-ILA Annuity & Savings Plan Participant Hardship Statement Important: Use this form for or hardship withdrawals when the safe harbor determination of hardship is used
More informationParent Special Condition Request (SPCOND)
To submit the completed form: In person: MT One Stop, Student Services and Admissions Center (SSAC) Mail: MTSU, MT One Stop, SSAC Room 260, 1301 East Main Street, Murfreesboro, TN 37132 Fax: (615) 898-5167
More informationTax Return Questionnaire Tax Year
Tax Return Questionnaire - 2015 Tax Year - Page 1 of 9..Fold here-then flip pages up Tax Return Questionnaire - 2015 Tax Year Name and Address: Taxpayer: Address: Social Security Number: Occupation Spouse:
More informationProfessional Judgment Review Application: Academic Year
Professional Judgment Review Application: Academic Year 2018-2019 PRFJ The application will be returned if all pages are not completed in full or if pages are missing from the submission. STUDENT S NAME:
More informationPlease sign and date application before returning to the Financial Counselor.
***FINANCIAL ASSISTANCE APPLICATION*** Instruction Sheet Please be sure to attach a copy of the following to the completed application: 1. Copy of last paycheck stub, Social Security or Disability check
More informationHARDSHIP WITHDRAWAL INFORMATION
HARDSHIP WITHDRAWAL INFORMATION You have requested paperwork to apply for a Hardship Withdrawal from your fringe account with MassMutual. Please be advised that the reverse sheet includes THE ONLY reasons
More informationPatient Financial Assistance Policy. The following criteria will be used to determine eligibility.
! Patient Financial Assistance Policy POLICY: St. Luke Community Healthcare, a not for profit hospital and affiliated medical clinics offering a broad range of medical care, and is committed to providing
More informationMaryland State Uniform Financial Assistance Application
Information About You Maryland State Uniform Financial Assistance Application Name First Middle Last Social Security Number - - Marital Status: Single Married Separated US Citizen: Yes No Permanent Resident:
More informationMotion for Modification of Child Support Order
Petitioner vs Respondent Case Number Motion for Modification of Child Support Order Failure to provide the Petitioner s, Respondent s, and Attorney s complete information WILL delay the filing of this
More informationPROFESSIONAL JUDGMENT REVIEW APPLICATION (Academic year)
PROFESSIONAL JUDGMENT REVIEW APPLICATION 2016-2017 (Academic year) PRFJ ALL APPLICANTS ARE REQUIRED TO COMPLETE THIS SECTION. (THE APPLICATION WILL BE RETURNED IF ALL APPLICABLE PAGES ARE NOT COMPLETED
More informationREQUIRED DOCUMENTS FOR RENTAL COUNSELING APPOINTMENT
REQUIRED DOCUMENTS FOR RENTAL COUNSELING APPOINTMENT Appointment Time: Please Note: You MUST bring the following documents your counseling session in order receive counseling. You are REQUIRED take everything
More information2017 Tax Return Questionnaire
2017 Tax Return Questionnaire Directions: Print and complete this form prior to your consultation. Bring it with you when you come to the office or contact us for email or fax instructions. Preparing this
More informationWould you like to make sure your request is processed as fast as possible?
UNFORESEEABLE EMERGENCY WITHDRAWAL FORM Would you like to make sure your request is processed as fast as possible? ICMA-RC knows the answer is YES! Follow the steps shown below to ensure we are able to
More informationFamily Assistance Program
Family Assistance Program The Children s Cardiomyopathy Foundation (CCF) Family Assistance Program was established in 2011 through the generous donations of CCF family members. The fund was set up to assist
More information1040 US Tax Organizer
1040 US Tax Organizer CEDRIC V. ALEXANDER, EA CFP 1900 POWELL STREET, SUITE 6020 EMERYVILLE, CA 94608 Telephone number: Fax number: E-mail address: (877) 336-2626 (877) 683-6618 CVA@CLERGYTAXFINANCIAL.ORG
More informationApplication for Lifeline Telephone Service
Important Lifeline Information Lifeline is a service and a government assistance program designed to make phone and internet services more affordable for low-income customers. Assistance is provided in
More informationHardship Withdrawal Guidelines
1015 A Street Tacoma, WA 98402 800-610-8920 TrueBlue.com NYSE Symbol: TBI Hardship Withdrawal Guidelines If you experience certain financial hardships while you are employed, you can request payment of
More informationName: Date of birth: Social Security #: Relationship: Months lived in home:
Peter Morales Tax Service Tax Organizer Tax Organizer Form This form will help you to organize your tax information. Please print it out, complete as much of it as you can and bring it with you when you
More informationDear Customer: Time is critical and an immediate response is your first step toward finding a solution.
Dear Customer: We understand that you may be experiencing financial problems that could result in the foreclosure and loss of your home. We also understand that the temporary or longterm difficulties that
More informationTDA HARDSHIP WITHDRAWAL APPLICATION
TDA HARDSHIP WITHDRAWAL APPLICATION INSTRUCTIONS PLEASE READ CAREFULLY Under the Internal Revenue Code (IRC), Tax-Deferred Annuity (TDA) Program participants who are under age 59½ may withdraw their post-1988
More informationIndividual Income Tax Organizer 2016
MICHAEL R. ANLIKER, CPA, P.C. 5348 Twin Hickory Rd. Glen Allen, VA 23059 TELEPHONE: (804) 237-6044 FAX: (804) 237-6064 www.anlikerfinancial.com Individual Income Tax Organizer 2016 This Tax Organizer is
More informationCHILD CARE FINANCIAL ASSISTANCE Day Care Program - Application for IMPORTANT PLEASE READ
Checklist IMPORTANT PLEASE READ To qualify for Child Care Financial Assistance you must answer to the following questions: Are you and your child a resident of New Trier Township? Is this program state
More informationTax Return Questionnaire Tax Year
Print this form out, take some time to fill it out, and bring it with you when you come to the office. This will save you time and money, and help us help you more effectively. Tax Return Questionnaire
More informationApplication and Home Buyer s Document Checklist for City Housing program eligibility. The Checklist will instruct you about application attachments.
Neighborhood and Business Development City Hall Room 005A, 30 Church Street Rochester, New York 14614-1290 www.cityofrochester.gov HOME BUYER SERVICES Attached are your: Bureau of Business and Housing
More informationREQUEST FOR DISTRIBUTION
Normal Processing RUSH Processing (Additional $60 Fee applies except for QDRO) REQUEST FOR DISTRIBUTION Note: Time sensitive material. Please complete this form carefully. Missing information may delay
More information1040 US Tax Organizer
40 US Tax Organizer Page 1 CLIENT INFORMATION First name and initial..... Last name............... Title/suffix............... Social security number... Occupation.............. Date of birth (m/d/y)......
More informationMcALISTER OIL 401(k) PLAN (k) SAFE HARBOR NOTICE
McALISTER OIL 401(k) PLAN 2019 401(k) SAFE HARBOR NOTICE In accordance with IRS rules we are required to provide you with a summary of the 401(k) and employer contribution features of the McAlister Oil
More informationEMERGENCY SHELTER GRANT APPLICATION (Please be advised; this is a once in a life-time grant)
EMERGENCY SHELTER GRANT APPLICATION (Please be advised; this is a once in a life-time grant) Application Date: The Emergency Shelter Grant is a ONCE IN A LIFETIME assistance program. These monies may be
More informationImportant Notice regarding the Airconditioning and Refrigeration Industry Defined Contribution Retirement Plan Hardship Withdrawal Guidelines
3500 W. ORANGEWOOD AVE., ORANGE, CA 92868 PHONE: (714) 917-6100 FAX: (714) 917-6065 Important Notice regarding the Airconditioning and Refrigeration Industry Defined Contribution Retirement Plan Hardship
More informationGeneral Information for 401k Plan Participant
General Information for 401k Plan Participant Welcome to our 401(k) Guide for the Plan Participant! The information contained on this site was designed and developed by various governmental agencies, and
More information***Please keep this page for your records***
HARDSHIP CHECKLIST Please use this checklist to ensure that you have completely and accurately filled out the application. All documentation will be reviewed and does not guarantee the approval of your
More informationUnforeseeable Emergency Withdrawal Request For 457 Supplemental Retirement Program
Municipal Employees Retirement System of Michigan 800.767.MERS (6377) www.mersofmich.com Unforeseeable Emergency Withdrawal Request For 457 Supplemental Retirement Program Frequently Asked Questions What
More informationPlease complete and return to: Monroe County Habitat for Humanity 354 Memorial Blvd Tobyhanna,PA Phone: (570)
Monroe County Habitat J I I for Humanity Please complete and return to: Monroe County Habitat for Humanity 354 Memorial Blvd Tobyhanna,PA 18466 Phone: (570) 216-4390 Dear Applicant, Thank you for your
More informationApplication for Assistance
Atria Cares Application for Assistance PROGRAM GUIDELINES Atria Cares, Inc. is a public, nonprofit 501(c)(3) organization that grants temporary/short-term financial assistance to qualifying employees of
More informationSUN-KAP ENTERPRISES,LLC TAX AND FINANCIAL PLANNING 1260 Huntington Dr., Suite 205 South Pasadena, CA Phone Fax
SUN-KAP ENTERPRISES,LLC TAX AND FINANCIAL PLANNING 1260 Huntington Dr., Suite 205 South Pasadena, CA 91030 Phone 323-254-2729 Fax 323-254-2739 NOTE: REMEMBER TO BRING ALL OF YOUR W-2, 1099, 1098, K-1 AND
More informationChildren s National Financial Assistance Application
Children s National Financial Assistance Application Children s National will offer financial assistance to patients who are unable to pay their hospital and/or clinic bills due to difficult financial
More informationRENTAL APPLICATION. Property Applying For: * When do you want or need to move in: Have you Viewed this Property?
Southern Homes 205 E. Madison Ave. Athens, TN 37303 Office (423) 744-3515 Fax (423) 744-3516 RENTAL APPLICATION Date: Property Applying For: * When do you want or need to move in: Have you Viewed this
More informationARTSPACE EL PASO LOFTS
ARTSPACE EL PASO LOFTS Dear Applicant: Welcome to Artspace El Paso Lofts and thank you for your interest in our new and exciting community! To expedite your application process, below are basic instructions
More informationThe Connecticut Tech Act Project s Assistive Technology Loan Program
The Connecticut Tech Act Project s Assistive Technology Loan Program LOAN APPLICATION PACKET CT Tech Act Project, AT Loan Program 55 Farmington Avenue, 12th floor Hartford, CT 06105 Voice: (860) 424-4881
More informationThis is a list of items you should gather for the Income Tax Preparation
This is a list of items you should gather for the Income Tax Preparation 1. Social Security Card(s) - Your Social Security number, which is your taxpayer identification number, is printed on your Social
More informationHemminger & Associates, Inc. Income Tax Service Please Read!
Dear Client; Hemminger & Associates, Inc. Income Tax Service Please Read! We ve moved to 6915 Lakewood Dr. W Suite A3 Tacoma, WA 98467 Referrals! We would like you to pass our name to someone you think
More information1040 US Tax Organizer
1040 US Page 1 Folino Tax & Financial Network 333 N. Lantana St. Suite 297 Camarillo, CA 93010 Telephone number: Fax number: E-mail address: (805) 482-4062 (805) 482-8910 david@folinotax.com Tax Return
More informationThe St Mary Medical Center Financial Assistance program does not cover the cost from all physician offices.
Dear St. Mary Medical Center is committed to providing high quality care to all in our community. We may be able to assist you with your medical bills if you are not able to afford them. Please read the
More informationHousing Assistance Application Check Sheet
Housing Assistance Application Check Sheet In order to determine eligibility, the following items are required for all household members: [ ] Application update required annually [ ] Degree of Indian Blood-copy
More information<Agent Information> Re: Loan # Property Address: Dear <Agent>
Re: Loan # Property Address: Dear Homecomings Financial will consider a request for a short payoff on the above referenced property upon receipt of the financial information
More information1040 US Tax Organizer
1040 US Tax Organizer Page 1 CLIENT INFORMATION First name and initial..... Last name............... Title/suffix............... Social security number... Occupation.............. Date of birth (m/d/y)......
More informationFinancial Needs Analysis Questionnaire (the involvement of ALL decision makers are required for an accurate assessment) Date: Time:
Primary: D.O.B. Spouse / Partner: D.O.B. Address Primary s Cell phone: Home Phone: Spouse / Partner Cell phone: Primary s e-mail Spouse / Partner s e-mail Height Weight Any form of tobacco use? Height
More informationCONSUMER LOAN APPLICATION
CONSUMER LOAN APPLICATION Bring In: Pay stubs from the last 30 days Fill Out & Sign: Application Covered Borrower Identification Statement Borrower Email Address: CONSUMER CREDIT APPLICATION IMPORTANT
More informationQualified Retirement Plan PENSCO Solo(k) Summary Plan Description. Standardized Individual 401(k) Profit Sharing Plan
Qualified Retirement Plan PENSCO Solo(k) Summary Plan Description Standardized Individual 401(k) Profit Sharing Plan Standardized Individual 401(k) Profit Sharing Plan Summary Plan Description Plan Name:
More informationThe following criteria must be met to be eligible for financial assistance from Champlain Valley Physicians Hospital:
Champlain Valley Physicians Hospital 75 Beekman St., PO Box 2868 Plattsburgh, New York 12901 518-562-7074, 844-281-0023 Fax: 518-314-3981 patientaccounting@cvph.org Dear Applicant, Thank you for choosing
More informationHemminger & Associates, Inc. Income Tax Service Please Read!
Dear Client; Hemminger & Associates, Inc. Income Tax Service Please Read! This organizer is for the tax year 2018. Please use it as a guide in gathering together your 2018 tax information. Bring it with
More informationTax Return Questionnaire Tax Year
Tax Return Questionnaire - 2018 Tax Year - Page 1 of 18 Print this form out, take some time to fill it out, and bring it with you when you come to the office. This will save you time and money and help
More informationRental Program Application
Rental Program Application How to Apply To apply for a unit with Youngstown Neighborhood Development Corporation please obtain a Available Housing List from the Youngstown Neighborhood Development Corporation
More informationSpecial Circumstance Form
ID# Phone # NDSU Email Have you submitted a Special Circumstance Form to NDSU in any previous year? Special Circumstance Form 2018-19 If you are completing this form you are requesting that financial aid
More informationEligibility Checklist
Eligibility Checklist Patient s Name: of Service: /_/ Medical Record #: _ Account Number: _ You are encouraged to apply one week prior to any appointments with proof of appointment and/or referral. In
More informationWithdrawals. Hardship Withdrawals
Withdrawals The Plan s primary purpose is to provide benefits when you retire. However, under certain circumstances, you may be able to withdraw money from your account while you are still employed by
More informationAPPLICATION FOR AFFORDABLE HOUSING
APPLICATION FOR AFFORDABLE HOUSING WELCOME! We are very happy you are interested in Our Family Services affordable apartments. Our units are spacious, comfortable with a washer and dryer in each unit.
More informationQUALIFIED RETIREMENT PLAN SUMMARY PLAN DESCRIPTION
QUALIFIED RETIREMENT PLAN SUMMARY PLAN DESCRIPTION SUPER SIMPLIFIED STANDARD INDIVIDUAL 401(K) PROFIT SHARING PLAN Plan Name: Your Employer has adopted the qualified retirement plan named above ( the Plan
More informationThe Lee Accountancy Group, Inc th Street Oakland, CA
January 22, 2016 The Lee Accountancy Group, Inc. 369 13th Street Oakland, CA 94612-2636 Client, Dear : The Tax Organizer will assist you in collecting and reporting information necessary for us to properly
More informationSupplemental Retirement Plan Comparison Chart
Supplemental Retirement Plan Comparison Chart This table summarizes the major provisions of and the State (of Illinois) Employees Deferred. Every effort has been made to make this table as accurate as
More informationMassachusetts Department of Transitional Assistance
DTA - DPC P.O. Box 4406 Taunton, MA 02780-0420 Massachusetts Department of Transitional Assistance Name: Address: City/Town: Your Monthly Report From To Name If your name, address or telephone is DIFFERENT,
More informationSavings Plus Program 457 Deferred Compensation Plan Unforeseeable Emergency Withdrawal Form
Savings Plus Program 457 Deferred Compensation Plan Unforeseeable Emergency Withdrawal Form Please read the instructions and information on pages 3 and 4 before completing this form. SECTION I Participant
More informationGAITA & LISZT, P.L. -A Professional Law Practice- Bankruptcy Document Checklist
GAITA & LISZT, P.L. -A Professional Law Practice- Bankruptcy Document Checklist The following documents will be required to complete your bankruptcy petition. You only need to provide the documents that
More informationSolutions Network Tax Services
Solutions Network Tax Services Fax 877 469 4558 Phone 877 604 6636 ext 3 Information Needed to Prepare U.S. Tax Return Please send copies of W2s, and evidence of foreign income (if any) and any 1099s received.
More informationCommunity Memorial Health System To apply in person: 147 North Brent Street 5855 Olivas Park Drive Ventura, CA Ventura, Ca 93003
Community Memorial Health System To apply in person: 147 North Brent Street 5855 Olivas Park Drive Ventura, CA 93003 Ventura, Ca 93003 REQUEST FOR FINANCIAL ASSISTANCE UNCOMPENSATED CHARITY CARE APPLICATION
More informationAccessing retirement funds
Accessing retirement funds Considering withdrawing your retirement money to meet a current financial need? The United Methodist Personal Investment Plan (UMPIP) is designed to provide retirement income.
More informationYOUR APPLICATION MUST BE COMPLETED IN IT S ENTIRELY BEFORE IT CAN BE PROCESSED.
ALL APPLICATION MUST BE COMPLETED AND MAILED TO THE FOLLOWING ADDRESS: ATTENTION: LALISA SUMMERS PLACEMENT NETWORK TRANSITIONAL HOUSING 5279 1/2 WIGHTMAN STREET SAN DIEGO CA 92105 INSTRCTIONS FOR APPLICATION
More informationAPPLICATION FOR FINANCIAL ASSISTANCE / SCHOOL YEAR
APPLICATION FOR FINANCIAL ASSISTANCE 2016-2017 / 5776-5777 SCHOOL YEAR MECHINA HIGH SCHOOL and the CENTER FOR THE ADVANCEMENT OF JEWISH EDUCATION APPLICATION FOR FINANCIAL ASSISTANCE 2016-2017 / 5776-5777
More informationPURCHASE ASSISTANCE PROGRAM COMMUNITY DEVELOPMENT DEPARTMENT
PURCHASE ASSISTANCE PROGRAM COMMUNITY DEVELOPMENT DEPARTMENT CITY OF NORTH LAUDERDALE 701 SW 71 AVENUE NORTH LAUDERDALE, FLORIDA 33068 If you have not owned a home in the past three years and are interested
More information