Financial Wavier
Please fill this form out completely. Email required documentation at the email below. Please note, we CAN NOT approve incomplete applications or applications without proper documentation.
* Required
Email address
*
Your email
Name
*
Your answer
Address
*
Your answer
Phone
*
Your answer
Email
*
Your answer
Household Members (age, gender, relationship)
*
Your answer
Financial Assistance
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Yes
No
Disability
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Yes
No
Food Stamps
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Yes
No
Social Security
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Yes
No
Social Security Disability
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Yes
No
Unemployment
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Yes
No
Worker's Compensation
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Yes
No
Total monthly gross income (including all members of the household)
*
Your answer
Program you are requesting assistance for
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Your answer
Did you submit a copy of your financial assistance income and proof of residence to
admin@halok9behavior.com
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Yes
No
I understand that if ALL documentation is not submitted to HALO within 7 days, that my request will not be considered
*
Yes
No
I certify that all of the above information is true accurate (type name)
*
Your answer
Please type your name below
*
Your answer
I agree that by typing my name above this is a legal digital signature
*
Yes
No
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