1. Customer Support
  2. Financial Assistance Programs

Financial Hardship Statement

Account Holder

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Resources

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Income - All household income within the last 30 days for
everyone that lives
in the home that is 18 years of age or older.
Net Income:
• Pay Stubs (last 30 days)
• Bank statement showing direct deposit/proof of paid bills etc.
• Food stamps award letter
• Other sources of income (provide proof)

We will consider:
• Notarized statement from employer
• Notarized letter from parent, tenant, etc.
Notarized letters should include date received and dollar amount

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Monthly Expenses

Expenses - Proof of PAID expenses within the past 30 days
Only PAID Bills:
• 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 payments

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)

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Monthly Household Income

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Household Members

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I certify that the above financial information on this form is true and correct to the best of my knowledge.