APPLICATION FOR FINANCIAL HARDSHIP DEFERRAL
Name ____________________________ age _________
Name ____________________________ age _________
Address _______________________________________________
City _______________________________ Zip _________
Ages of Dependents ____________________ Phone ___-___-____
Parcel ID# ___-___-___-__
EMPLOYMENT: MONTHLY INCOME:
Company _________________ _____________________
Address ________________________________
Social Security (not your S.S. # - just the amount you receive monthly)_____________________________________________________
Social Security (not your S.S. # - just the amount you receive monthly)______________________________________________________
Assistance (example: DHS for food stamps, etc.) ______________________________________________________
Assistance (example: DHS for food stamps, etc.) ______________________________________________________
Other Income List: (example: child support, etc.) ______________________________________________________
TOTAL MONTHLY INCOME ________________________________
When meeting with the Treasurer you must provide proof if income, last two (2) years of State & Federal tax forms, the Financial Statement below, and any other documents necessary to present your case. If there are special conditions or circumstances you would like considered, please list on the back of the application or send additional pages.
FINANCIAL STATEMENT – STATEMENT OF CONDITION AS OF TODAY’S DATE
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ASSETS
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LIABILITIES
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MONTHLY PAYMENT
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TOTAL OWED
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CASH ON HAND
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$
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MORTGAGE
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$
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|
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CHECKING ACCOUNT
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$
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CREDIT CARDS
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$
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|
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SAVINGS ACCOUNT
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$
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AUTOMOBILE
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$
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SAVINGS BONDS
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$
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AUTOMOBILE
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$
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|
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STOCKS & SECURITIES
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$
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PROPERTY TAXES
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$
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|
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HOME
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$
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LAND CONTRACT
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$
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|
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CASH VALUE LIFE INS.
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$
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ELECTRICITY
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$
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|
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AUTOMOBILE
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$
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HEAT
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$
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|
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AUTOMOBILE
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$
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PHONE
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$
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|
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FURNITURE/HOUSEHOLD ITEMS
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$
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INTERNET
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$
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|
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RECREATIONAL VEHICLES
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$
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|
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TOTALS
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$
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$
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Retirement, IRA, 401(k)
Other Assets > $1,000 in value (list)
______________________________
______________________________
Net Worth : $_______________________________________________ (total assets – total liabilities = net worth)
Total Assets: $___________________ = Total Liabilities & Net Worth $___________
The above statements are true to the best of my knowledge and belief and are made for the purpose of obtaining a Hardship Deferral on my homestead property for Delinquent Real Property Taxes.
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Signature
________________________________
Date
________________________________
Signature
___________________________________
Date
Return Application to: Financial Hardship Deferral Application,
Ionia County Treasurer’s Office, 100 Main Street, Ionia, MI 48846
Questions? Call (616) 527-5329