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Financial Assistance Request
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Recipient Phone Number*
Monthly Income*
Source of Income*
Social Security
Pension
Disability
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Other
Housing Costs*
Housing Mortgage / Rent / Insurance
Utilities*
Gas/Electric/Water/Sewer/Trash Pick-up
Connect to Others*
Phone / TV (cable) / Internet
Vehicle *
Car Payment / Car Insurance / No vehicle expenses
Medical*
Out of pocket Prescription Costs /Monthly Medical Bills
Medical Insurance*
Insurance Premiums / Co-Pays / No Expenses
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