AHA Application

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Associates applying for the AHA Fund can apply for up to $1,000 within a 12-month time period. The AHA Fund will also provide up to 20% of the funds needed for approved KWCares Grant Applications.

Per the ALC Voted in November 2018, the Team Leader can create up to 1 month office bill or provide a gift card from the AHA Fund up to $89 without committee approval. Application must be filled out by the Team Leader and provided to the committee members at the next committee meeting.

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– Step 1 of 6

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Submitted By *AgentTeam Leader

Amount Requested *

Description of Need *

Any Additional Information:

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Financial Condition

Please enter amounts in numeric values only. If none, just enter ‘0’.

Financial Condition

Cash *

Savings Accounts *

Checking Accounts *

Other Accounts *

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Statements

Please complete the fields below – enter your monthly payment and attach your most recent statement for each of the following:

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Mortgage / Rent

Mortgage Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing mortgage or rent payment.

Vehicle Loans

Vehicle Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing vehicle payment.

Vehicle Insurance

Vehicle Insurance Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing vehicle insurance payment.

Utilities

Utilities Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing utility payment.

Credit Cards

Credit Card Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing credit card payment.

Student Loans

Student Loan Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing student loan payment.

Medical Insurance

Medical Insurance Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have an existing medical insurance payment.

Other Debts

Other Debts Statement *

Click or drag a file to this area to upload.

A recent statement must be uploaded if you have other existing debt payments.

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Insurance

Please complete the fields below – state whether or not you have each type of insurance and when it expires.

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Health Insurance *

• Yes
• No

Expires *

Medicaid *

• Yes
• No

Expires *

Medicare *

• Yes
• No

Expires *

Prescription Drug *

• Yes
• No

Expires *

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Members of Household

Please enter the following information about members of your household. Names are not needed.

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Relation

Relation

Relation

Relation

Relation

Age

Age

Age

Age

Age

Dependent?NoYes

Dependent?NoYes

Dependent?NoYes

Dependent?NoYes

Dependent?NoYes

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Certification of Application

This is to certify that I have reviewed the KWP AHA gift criteria and the information submitted is accurate. I hereby give the KWP AHA Committee permission to ask for more information if needed.

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Name *

Mobile Phone *

Signature (as Initials) *

Email *

Email

Confirm Email

Submit