Eagle Insurance Group Financial Affidavit For Hardship Page 3
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4EAGLE INSURANCE GROUP
APPLICATION FOR HARDSHIP DISTRIBUTION
Item 3: ASSETS
Cash on hand or in banks ................................................................................................................... $ ____________
Stocks, Bonds, Notes.......................................................................................................................... $ ____________
Real Estate ......................................................................................................................................... $ ____________
Home .................................................................................................................................... $ ____________
Other……………………………………………………………………………….. ....................... $_____________
Automobiles ........................................................................................................................................ $ ____________
Life Insurance/Annuity Contracts (Total Cash Value) ......................................................................... $ ____________
Other Personal Property ..................................................................................................................... $ ____________
Other Assets (Please describe below) ................................................................................................ $ ____________
____________________ .................................................................................................................... $ ____________
____________________ .................................................................................................................... $ ____________
____________________ .................................................................................................................... $ ____________
TOTAL ASSETS .................................................................................................................. $ ____________
Item 4: LIABILITIES
Real Estate Mortgages ....................................................................................................................... $ ____________
Automobile Loans ............................................................................................................................... $ ____________
Other Notes and Loans ....................................................................................................................... $ ____________
Other Liabilities (Please describe below) ............................................................................................ $ ____________
___________________ ...................................................................................................................... $ ____________
___________________ ...................................................................................................................... $ ____________
___________________ ...................................................................................................................... $ ____________
TOTAL LIABILITIES ............................................................................................................ $ ____________
PLEASE NOTE THAT “HOUSEHOLD” INCLUDES SPOUSE/DOMESTIC PARTNER OR OTHER RELATIVE WHO IS
18 YEARS OLD OR OLDER RESIDING AT THE SAME ADDRESS AS THE APPLICANT.
NOTE: Please provide copies of your last tax return filed with IRS, most current bank statements, mortgage
stubs, loan stub, pay stubs and any all other financial information that will assist us to expedite the process.
I understand that this Application can be approved only if the immediate and pressing financial need which occasioned
the application cannot be relieved by other financial resources that are reasonably available to me. Further, I
understand that the amount distributed cannot exceed the amount required to relieve the financial need and that
I may receive a smaller amount than requested.
Therefore, in support of this Application and the representations made herein, I submit the attached documentation (such
as copies of actual invoices, pictures, detail explanations, etc.) as proof of the purpose and amount requested, and I
hereby certify the financial need that occasioned the application cannot be relieved:
1.
Through reimbursement or compensation by insurance or otherwise;
2.
By borrowing from any commercial institution (such as a bank, credit union, saving and loan, etc.) on
reasonable terms or from any familial sources, or through other available resources of my spouse/domestic
partner, children, parents or other relatives;
3.
By reasonable liquidation of my assets, to the extent such liquidation would not itself cause an immediate and
pressing financial need;
4.
By cessation of salary reduction contributions to any type savings or retirement plans (such as 401K, IRA, Tax
Shelter Annuity, 457, purchasing of savings bonds, etc.);
5.
By any other available distributions or loans from any source (such as savings or retirement plans maintained by
my employer or the employer of my spouse/domestic partner or other relative, IRA, life insurance policies,
annuities, etc.); or
6.
By any other person, whether a member of your household or not (such as a spouse/domestic partner, relative,
employer, other insurance company, charitable organization, etc.) obligated by law, contract or otherwise, to
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