Please describe any circumstances that will help us understand your request for financial assistance at this time: {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Personal Financial Statement - to be completed by individuals responsible for payment.
Financial Partner Name(s)
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Financial Partner Name {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Guest Name {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Date {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Income (Partner/ Guarantor/Guest)
Partner#1 AGI from most recent 1040 {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Other Income (please identify) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Partner#2 AGI from most recent 1040 {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
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Client income from most recent 1040 {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Client income from SSI/SSDI {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
Other (please specify) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
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Required Documents
Two most recent federal income tax returns from the individual responsible for payment of services (guarantor). Please send only the first two (2) pages.
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SIGNATURES: I hereby state that the information provided is accurate and complete to the best of my ability. Gould Farm reserves the right to verify all information provided.