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

Submitted By *AgentTeam Leader

Amount Requested *

Description of Need *

Any Additional Information:

Next

Financial Condition

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

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:

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.

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.

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.

Name *

Mobile Phone *

Signature (as Initials) *

Email *

Email

Confirm Email

Submit