REQUEST TO REDUCE WITHHOLDING DUE TO HARDSHIP All information must be provided for the request to be considered. Your application will be returned for clarification if it is incomplete (we will highlight missing items). You will receive an answer by mail. If you have any questions, you may contact CSSD at 269-6900. CSSD Case Number: ___________________ Full Name: ___________________________ SSN or CSSD MEMBER ID: ______________ Date of Birth: _________________ Current Address: _________________________________ How Long? _____________ _________________________________ _________________________________ Reasons for this request (be specific) (if additional room is needed continue on reverse) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Telephone: Home: ________________. Work: ________________________ If less than five years, provide previous 2 addresses: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Have you been incarcerated for more than one year? ___ Yes ___ No Current Employer: ______________________________ How long? _________ ______________________________ Gross Earnings: _________ ______________________________ 1 CSSD 04-0009 (Rev 04/25/2005) American LegalNet, Inc. www.USCourtForms.com **I have attached the last two months of pay stubs and last years complete income tax return _____Yes _____No (Why on reverse) * *Failure to provide this documentation could result in the denial of this request. If employed less than 2 years, previous 2 employers: ______________________________ How long? _________ ______________________________ ______________________________ Phone # _______________ ______________________________ How long? _________ ______________________________ ______________________________ Phone # _______________ Do you have any other source of income? ___ Yes, ___ No If yes, what is the source: ____________________ How much? _________ (Monthly/yearly) (Continue on reverse if necessary) 1. Household members (People living with you) If there are more than 4, use the back of the form to list additional members: Name Age Relationship ________________________ ________________________ ________________________ ________________________ __________ __________ __________ __________ ______________________________ ______________________________ ______________________________ ______________________________ 2. Your Household Income: Yours a. Current Monthly Income: Wages: Social Security: Public Assistance: Unemployment: Other (specify) ____________ ________________________ Total Monthly Income: Others (spouse, roommate etc) $ _____________ $ _____________ $ _____________ $ _____________ $ _____________ $______________ $______________ $______________ $______________ $______________ $ _____________ $______________ b. Permanent Fund Dividends received in last 12 months $ _________ c. Native/Tribal or other corporate dividends received in last 12 months $ _________ Source of dividends: _____________________________________________ ______________________________________________________________ 2 CSSD 04-0009 (Rev 04/25/2005) American LegalNet, Inc. www.USCourtForms.com d. Total household Income during last 12 months: $ _________ e. Do you expect to receive other income within the next 6 months (gifts, Settlements, dividends or inheritances)? ____ Yes, ____ No f. Do you have a business license? ___ Yes, ___ No Name of business if yes: ________________________ 3. Monthly Household Expenses: Expenses Yours Others (spouse, roommate etc) Food Housing: Rent/Mortgage Utilities: Gas, Elec., Water Garbage, Telephone Transportation (gas/bus) Car Payment Through who: __________ ______________________ Insurance Car Health Child Support/Alimony List Loans & Credit Card Debts: _______________ _____________________ _____________________ _____________________ _____________________ $_______ $ _______ $ _______ $ _______ $ _______ $ _______ $__________ $__________ $__________ $__________ $__________ $__________ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $__________ $ ________ $__________ *Medical (not covered by ins) *Provide copies of bills Childcare Miscellaneous Expenses Cable TV Club Membership Fees Internet Fees Subscriptions (newspaper) Entertainment Alcohol/Tobacco $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $ _______ $__________ $__________ $__________ $__________ $__________ $__________ Total $ _______ $__________ *extraordinary expenses are taken into account but must be substantiated with documentation 3 CSSD 04-0009 (Rev 04/25/2005) American LegalNet, Inc. www.USCourtForms.com 4. Cash and Assets: (Things you own or are buying) include all things you own by yourself and all things you own jointly with someone else. If owed jointly, with whom _________________ __________________________________________________________________________ Cash $ __________ Balance Bank Acct./Checking $ __________ Bank Acct/Savings $ __________ Stocks, Bonds, CD’s, Mutual Funds Retirement Plans Bank Name: ________________ ___________________________ Bank Name: ________________ ___________________________ With Whom: _________________ ____________________________ With Whom: _________________ $ __________ $ __________ $ __________ Items: List below, land, homes, trailers, motor vehicles, snow machines, ATVs, boats, airplanes, motorcycles. If financed, please list the financing company and the terms of the contract on a separate sheet of paper and attach to this statement. _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ Value $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ $ __________ Amount Still Owed $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ Jointly owned Yes___ No__ Yes___ No__ Yes___ No__ Yes___ No__ Yes___ No__ Yes___ No__ Yes___ No__ Yes___ No__ Other: ________________ _____________________ _____________________ $ __________ $ __________ $ __________ $ ______________ $ ______________ $ ______________ Yes___ TOTALS: $ __________ (-) No__ $ _____________ = $ __________ Are any of the above items required to earn your living? ___ Yes, ___ No If yes, list the item and describe why you need it (continue on reverse if necessary) ______________________ _______________________________________________________________________ _______________________________________________________________________ I have completed this form to the best of my ability. I understand failure to disclose information or provide the required documents such as pay stubs and complete tax returns may result in the disapproval of this request. If I am eligible for the PFD, I will apply as an additional condition of this request. ____________________________ Date _____________________________ Printed Name _____________________________ Signature 4 CSSD 04-0009 (Rev 04/25/2005) American LegalNet, Inc. www.USCourtForms.com