Indigency Application

This Application for Indigency is a request to Healing Hearts Foundation to pay for one week of camp at Healing Hearts Haven's studios; by submitting this form, you are making a statement about your financial situation to help the Foundation decide whether to waive your fees for participation in the classes you choose. You are telling the Foundation that you cannot afford to pay the required fees. • Complete all required fields below in order to be considered. • All boxes must be checked, and you must agree with what each statement says. • Fill in the blanks with the most accurate information available to you. You may want to have a copy of your last tax return to help you. If you do not know an answer then place a question mark (“?”) in the blank. If you know for certain that you don’t have or receive the item in a paragraph then enter a zero (“0”).

First Name

Last Name

Phone Number

I am the Applicant named above and I make this application for the purpose of supporting my request to waive my class fees.

I do swear by checking this box that I am unable to pay for the required fees for services, and that I believe I am justifiably entitled to sponsorship by Healing Hearts Foundation.

I am:

Employed

Unemployed

Other

If employed, my monthly take-home pay is the following:

I get paid the following for retirement, disability, or insurance per month:

Total monthly income before deductions for 2021 was?

Total monthly income prior to deductions for 2022 is?

Including myself, I have the following total number of dependents:

I own the following types of assets:

Cash (on hand or in the bank)

Accounts and Notes Receivable (IOU's, unpaid invoices, or other money payable to me)

Investments (stocks, bonds, savings accounts)

Real Estate (houses, land, tribal lease, real property, etc.)

Automobiles

Household Goods (Furniture, Appliances, TV, Stereo, etc.)

Other Personal Property (Tools, Sports Equipment, Farm Equipment, etc.)

Any Other Assets (that could be sold or leased for money)

When I add the total monthly value of all my assets, it equals:

I have the following monthly liabilities:

Household Expenses (rent, utilities, gas, food, medical insurance, car insurance, etc.)

Credit Card or Loan Payments

Childcare Expenses (daycare, school lunch, after school programs)

Other

When I add the total value of all my monthly liabilities, it equals:

Anticipated Income:

I do have anticipated income from the sale of a house, land or other large asset

I do not have any anticipated income

If I do have anticipated income, I have the following monthly value in estimate returns:

Based upon the aforementioned information, I respectfully request the Healing Hearts Foundation consider my application for indigency and request for a waiver of the fees necessary to take part in Healing Hearts Haven's services.

I understand that if I am approved, I am bound to utilize the granted waiver within six months, otherwise, I will be required to reapply.

I also agree to be bound by all the terms and conditions, waivers, and policies required by Healing Hearts Haven.

Indigency Application

I am the Applicant named above and I make this application for the purpose of supporting my request to waive my class fees.

I do swear by checking this box that I am unable to pay for the required fees for services, and that I believe I am justifiably entitled to sponsorship by Healing Hearts Foundation.

I am:

Employed

Unemployed

Other

If employed, my monthly take-home pay is the following:

I get paid the following for retirement, disability, or insurance per month:

Total monthly income before deductions for 2021 was?

Total monthly income prior to deductions for 2022 is?

Including myself, I have the following total number of dependents:

I own the following types of assets:

Cash (on hand or in the bank)

Accounts and Notes Receivable (IOU's, unpaid invoices, or other money payable to me)

Investments (stocks, bonds, savings accounts)

Real Estate (houses, land, tribal lease, real property, etc.)

Automobiles

Household Goods (Furniture, Appliances, TV, Stereo, etc.)

Other Personal Property (Tools, Sports Equipment, Farm Equipment, etc.)

Any Other Assets (that could be sold or leased for money)

When I add the total monthly value of all my assets, it equals:

I have the following monthly liabilities:

Household Expenses (rent, utilities, gas, food, medical insurance, car insurance, etc.)

Credit Card or Loan Payments

Childcare Expenses (daycare, school lunch, after school programs)

Other

When I add the total value of all my monthly liabilities, it equals:

Anticipated Income:

I do have anticipated income from the sale of a house, land or other large asset

I do not have any anticipated income

If I do have anticipated income, I have the following monthly value in estimate returns:

I understand that if I am approved, I am bound to utilize the granted waiver within six months, otherwise, I will be required to reapply.

I also agree to be bound by all the terms and conditions, waivers, and policies required by Healing Hearts Haven.