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Please complete all sections below. Should a section not be applicable to you, acknowledge this by writing “N/A” in the available space. All submissions must be signed. Submitting a hardship request form is not a guarantee that an adjustment will be made.

Should you have any questions about the application, please direct them to Eve Grubb, Director of Operations.

Contact Information

Application Questions

Please provide dollar amount of lost income​
Please list a total dollar amount​


Max file size: 10 MB
Max file size: 10 MB

Agreements and Acknowledgements

Please initial below​​
Please initial below​​
Please initial below​

By initialing below, I attest that the information submitted here is true and accurate to the best of my knowledge. Intentionally providing false information will result in ineligibility for any form of hardship assistance and may impact future eligibility for financial assistance through the normal application process.

Please provide an email address where we can send a link to your current form.

Email Address :