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Finance & Legal
Financial Hardship Application
Let customers or members apply for temporary financial relief — hardship type, income and obligations, requested assistance, and supporting documentation.
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What this form looks like
Preview · not interactiveFinancial Hardship Application
Let customers or members apply for temporary financial relief — hardship type, income and obligations, requested assistance, and supporting documentation.
About you
Your name*
Email address*
We send decisions and next steps here.
Phone number*
Account or membership number*
From your statement or welcome email
Primary reason for hardship*
Select…▾
When did the hardship begin?*
Pick a date📅
Describe your situation*
Describe the hardship type
Currency for amounts below*
Select…▾
Current monthly household income*
0.00
All sources combined — salary, benefits, support payments.
Monthly fixed obligations*
0.00
Rent, utilities, loan minimums, insurance — recurring essentials.
Amount currently owed to us*
0.00
What assistance are you requesting?*
Temporary payment deferral
Reduced payment amount for a set period
Waiver of late fees or penalties
Structured payment plan
Monthly amount you could pay (if requesting a plan)
0.00
How long do you need relief?*
Select…▾
Supporting documents
⬆ Drop a file or click to upload
Termination letter, medical bills, insurance claim — anything that supports your application.
Application terms*
Application terms
Submit