Form Dc-1353-0313 - Financial Hardship Request Instructions And Application Form Maryland Page 3

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FINANCIAL HARDSHIP STATEMENT
PARTICIPANT NAME: _________________________________________________________________ SSN:________________________
ASSETS
CURRENT
(LESS)
(Include all property owned by you or your spouse)
VALUE
INDEBTEDNESS
NET WORTH
HOME ...............................................................................
$ ____________
$ ____________
$ ____________
OTHER REAL ESTATE.....................................................
$ ____________
$ ____________
$ ____________
AUTOMOBILES ................................................................
$ ____________
$ ____________
$ ____________
OTHER PERSONAL PROPERTY ....................................
$ ____________
$ ____________
$ ____________
CASH (CHECKING & SAVINGS) .....................................
$ ____________
$ ____________
$ ____________
STOCKS AND BONDS .....................................................
$ ____________
$ ____________
$ ____________
LIFE INSURANCE CASH VALUE.....................................
$ ____________
$ ____________
$ ____________
ALL OTHER ASSETS (LIST) ............................................
_________________________________________ ........
$ ____________
$ ____________
$ ____________
_________________________________________ ........
$ ____________
$ ____________
$ ____________
_________________________________________ ........
$ ____________
$ ____________
$ ____________
0
0
0
TOTAL ASSETS ...............................................................
$ ____________
$ ____________
$ ____________
CURRENT MONTHLY INCOME
CURRENT (MONTHLY) LIVING EXPENSES:
Net
Home mortgage payments or rent
$______________
Source
Monthly Income
Utilities (electric, water, phone)
$______________
Your salary
$ ____________
Food and clothing
$______________
Spouse’s salary
$ ____________
Medical expenses not covered by insurance
$______________
Car payments
$______________
Other income
$ ____________
0
Other transportation expenses
$______________
Total monthly income
$ ____________
Charge account payments (combined total)
$______________
College expenses of dependents
$______________
Insurance premiums (life, health, auto, etc.)
$______________
Other (list) ________________________
$______________
_________________________________
$______________
0
Total monthly living expenses
$______________
Please list the expenses directly related to this emergency which you are legally obligated to pay and attach a copy of
the applicable document.
BILLS OWED TO
AMOUNT
$
____________________________________________________________________________
$ ______________
____________________________________________________________________________
$ ______________
$ ______________
0
Total
$ ______________
DC-1353-0313
Page 3

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