Eagle Insurance Group Financial Affidavit For Hardship (Page 2 of 4) in pdf

EAGLE INSURANCE GROUP

APPLICATION FOR HARDSHIP DISTRIBUTION

THE COMPANY RESERVES THE RIGHT TO MAKE PAYMENTS DIRECTLY TO THE CREDITOR.

EAGLE INSURANCE GROUP

FINANCIAL AFFIDAVIT FOR HARDSHIP

Under penalties of perjury, I certify that the following statement of household income, assets and liabilities is true:

Occupation _____________________________________________________ No. of Dependents _________________

Employer Name _________________________________________________ Telephone No. ( ____ )______________

Employer Address _________________________________________________________________________________

Spouse’s/Partner’s Occupation __________________________ Employer Name _______________________________

Employer Address ______________________________________________ Telephone No. ( ____ )________________

Item 1: MONTHLY HOUSEHOLD INCOME

Average GROSS Monthly Household Wages (Provide copies of 2 current consecutive pay statements).$_____________

Less Deductions

Federal Income Tax……………………………………………$________________

Social Security………………………………………………….$________________

Other…………………………………………………………….$________________

Total Deductions……………………………………………………………………………………..$_____________

Average NET Monthly Household Wages………………………………………………………….…………$____________

State Unemployment Benefits (Provide copy of 1 unemployment statement)……………………………$____________

Annuity, Pension, Disability, or Retirement Income (Provide copy of statement)…………...……………$____________

Other Income (such as interest and dividends) (Please describe below)

___________________________________......................................................$________________

TOTAL NET MONTHLY HOUSEHOLD INCOME………...……...……………..............................$_____________

Item 2: MONTHLY HOUSEHOLD EXPENSES

Mortgage/Rent Payment ..................................................................................................................... $ ____________

Automobile Payment........................................................................................................................... $ ____________

Food.................................................................................................................................................... $ ____________

Clothing............................................................................................................................................... $ ____________

Incidentals........................................................................................................................................... $ ____________

Medical and Dental ............................................................................................................................. $ ____________

Transportation..................................................................................................................................... $ ____________

Utilities ................................................................................................................................................ $ ____________

Other Expenses (Please describe below)

____________________ .................................................................................................................... $ ____________

TOTAL MONTHLY HOUSEHOLD EXPENSES…………………………………………………$ ____________

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