Form Fs-H - Financial Statement For Claim For Hardship
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4Indiana Department of Revenue
FS-H
Claim for Hardship
SF# 53302
(R/5-07)
Financial Statement for Claim for Hardship
Please refer to pages and of this document to determine your eligibility and the requirements for this program. Your failure to
follow all instructions provided and submitting all required documentation will result with your application being rejected. You
will be notified within 15 to 20 working days, or less, if you have been accepted into or rejected from the Claim for Hardship
program.
Personal Information
Name:
Spouse’s Name:
Social Security Number:
Spouse’s Social Security Number:
Address:
Address:
City, State, Zip:
City, State, Zip:
Home Telephone Number: (
)
Home Telephone Number: (
)
Cell Phone: (
)
Cell Phone: (
)
Date of Birth:
Date of Birth:
Dependents
Please list the name, age and relationship of all dependents who live with you.
Name
Age
Relationship
Employment Information
Your Employer’s Name:
Spouse’s Employer’s Name:
Years Employed:
Years Employed:
Address:
Address:
City, State, Zip:
City, State,Zip:
Phone Number: (
)
Phone Number: (
)
Bank Account(s) Information
Please include all checking, savings, credit union accounts, Certificates of Deposit,
and list safety deposit boxes held by you, your spouse and dependents.
Type of Account
Financial Institution Name
Account Number
Present Balance
Page 3
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Parent category: Financial