Hardship

APPLICATION FOR HARDSHIP ASSISTANCE

Applicants Full Name

Address

Town

State

Zip

Phone

E-Mail

Please explain the details of your hardship:

Insurance Information:

Are the applicant’s medical bills covered in part by any of the following

Private Health Insurance

Medicare/Medicaid

Worker’s Compensation

Auto Insurance

Other

If other please explain:

If any insurance coverage exists, please give details of coverage and explain any out of pocket costs for you:

Employment Information

Applicant’s Occupation

Employer

Address

City

State

Zip

Spouse’s Occupation

Employer

Address

City

State

Zip

**If applicant is a child, the information above must be supplied by both parents.**

Financial Information:

To assure that our financial assistance is provided to those individuals with the greatest need, it is crucial that a copy of our most recent family’s 1040 Income Tax Return including all schedules and statements be submitted with your application.

Tax Files

Other Assistance:

If any other financial assistance has been provided or is in the formulation stages, please provide details:

Please Note: All the information appearing on this application will be treated in the strictest confidence. Any inaccuracies will automatically disqualify the applicant from consideration. The decision of the Philanthropic Committee will be final. Publication of the relative merits of the candidates will not be made. I, by the submitting below, attest to the truthfulness of all the statements made in this application and understand the contents thereof.

Applicant’s Initials

Send a copy of this message to your own address

Address all correspondence and return all applications to: Charles Pedrani Philanthropic Chairman 248 Madison Avenue Wyckoff, NJ 07481

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