Hardship
Exemption Application
page 2
SAVINGS AND INVESTMENTS: List all savings owned by you or your spouse, including savings accounts, postal savings, credit union shares, certificastes of deposit, cash, stocks, bonds or similar investments.
Name of Financial Institution or Investments Amount of Deposit Total Value of Investment
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LIFE INSURANCE: List all policies held by you and your spouse.
Name of Insured Amount of Policy Amount Paid Monthly
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MOTOR VEHICLES IN HOUSEHOLD:
Make Year Monthly Payment Balance Owed
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LIST ALL PERSONS LIVING IN HOUSEHOLD:
Last Name First Name Age
Relationship to
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PERSONAL DEBTS:
Creditor Purpose of Debt Monthly Payment Amount Balance Owed
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MONTHLY EXPENSES:
Utilities _____________________ Food _____________________ Phone ___________________________
Clothing _____________________ Heat ______________________ Car ______________________________
Other (Specify ) _________________________________________________________________________
OTHER ASSETS: List all other assests and their values that are owned or controlled by you. Example: boats, coin
Collection, antiques, etc.
Type of Asset Value Income Derived from Asset
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