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Financial Hardship Statement

Two Ways to Apply

To submit your application, simply tap APPLY NOW. Please be sure to have all required documents ready for upload. If you wish to fax or mail your application, tap DOWNLOAD and complete the application form. Please note, this option will greatly delay processing time. Application also available in Español.

Apply Now Download

Financial Hardship Agreement Instructions
If you're experiencing a financial hardship and need a below standard agreement, this application will be used to document your "paid expenses vs. your income". The results of the submission will determine your ability to make a payment. Once we receive and review all of the required documents, a representative will contact you to discuss the terms of the payment agreement.

Please note this financial hardship agreement is a one-time offer for the life of the account and should only be utilized during extreme circumstances.

Proof of Income Need for Application
Proof of income includes all household income within the last 30 days for everyone, 18 years of age or older, living in the same household. If there is no household income within the last 30 days, please apply for assistance at the Department of Social Services. Proof of income accepted is listed below. We will also consider notarized statements from employer or notarized letters from parent, tenant, etc.. Notarized letters should include date received and dollar amount. 

Net Income

  • Pay Stubs (last 30 days)
  • Bank statement showing direct deposit/proof of paid bills etc.
  • Food stamps award letter
 
Expenses
Proof of PAID expenses within the past 30 days Only PAID bills will be accepted:
 
  • Mortgage/Rent receipt
  • Heating oil
  • Gas
  • Electric
  • Propane
  • Car/Mass transit expenses (car loan, insurance, gasoline, metro card, LIRR)
  • Water
  • Sewer
  • Insurance (homeowners, car or life insurance)
  • Medical Expenses (co-pays, insurance, prescriptions)
  • Child care
  • Education/tuition
  • Child support
  • DSS payback
  • Loans
  • Court ordered payment

 
We will not accept:

  • Unpaid bills
  • Proof of income or expenses older than 30 days
  • Phone or cable bill (allowance already provided)
  • Food/Grocery bills (allowance already provided)
  • Zero income (you must show the ability to keep the payment agreement)