Form Csed-04-0009 - Request To Reduce Withholding Due To Hardship (2000)
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1REQUEST TO REDUCE WITHHOLDING DUE TO HARDSHIP
PLEASE PROVIDE ALL INFORMATION
CSED Case #: ________________________
Name: ______________________________
Names of Individuals in Household:
YOU MUST SUBMIT:
(1) LAST YEAR’S COMPLETE INCOME TAX RETURNS, &
(2) LAST 2 MONTHS OF PAYSTUBS
Reason for request (be specific):
IF ADDITIONAL SPACE IS REQUIRED USE THE REVERS SIDE OF THIS FORM
Total Monthly Income of Household:
Total Expenses:
Wages*
$
List household obligations
PFD
$
Rent or Mortgage Payment
$
Dividends
$
Electric
$
Social Security
$
Gas
$
Other Income (list)
Phone/Cell Phone
$
$
Water
$
$
Medical Bills
$
$
Garbage Pick-up
$
Clothing
$
Insurance (Auto/Life/Home)
$
*Wages should include all income from
Car Payments
$
every person in your current household
Food
$
that earns wages.
Total
$
Other Unusual Expenses - Please explain
Work Related Expenses
$
$
$
$
TOTAL:
$
NOTE:
1.
Examples of what we will NOT consider may include; expenditures made for recreation, comfort,
sport, investment, entertainment, private schools, travel, or recreational property.
2.
Usual household expenses are defined as items needed for the health and welfare of the family.
3.
You must apply for Permanent Fund Dividend (PFD).
SIGNATURE
DATE
CSED-04-0009 (Rev.02/02/00)
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