Living Expense Assistance Form

Intent

This voluntary form is intended to support house members who feel they could benefit from help managing living expenses or financial responsibilities. If you feel that you would benefit from financial coaching please fill out this form. Information provided will be used to help establish a starting point for financial coaching and support. Submitting this form does not alter corrective action status, change payment expectations, or balance requirements.

Name:

Client first nameClient last name

House:

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Phone Number:

Number field

Email:

Client email

Current Negative Balance:

Number field

Please describe the events or circumstances that led to your current financial situation:

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Are there any additional financial obligations currently impacting you?

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Date of next payment:

Date

Minumum amount contributing weekly:

(Must include the $200 weekly living expense plus an additional amount if you have a negative balance.)

Number field

What is your plan for sustainability?

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The following information will help a financial coach better assist you.

What challenges do you feel may impact your ability to stay current moving forward?

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What supports or tools do you feel would help you better manage your finances going forward?

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Is there anything else you would like the financial coach to know to better support you?

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IMPORTANT

Submitting this form does not absolve you of the obligation to pay the amount due by the agreed upon day and time. This form serves soley to support early communication and provide guidance if a member anticipates difficulty making a payment by the due date. Members remain accountable for all financial commitments, and failure to meet these obligations will result in corrective action, up to and including expulsion from the house.

By checking this box, you consent to this form being shared with financial coaches for the purpose of support and guidance.

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By checking this box, you acknowledge that you have read and understood the above information.

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Signature:

Signature

By continuing, you agree that your electronic signature is the legally binding equivalent to your handwritten signature. Whenever you execute an electronic signature, it has the same validity and meaning as your handwritten signature. You will not, at any time in the future, repudiate the meaning of your electronic signature or claim that your electronic signature is not legally binding.