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APPLICATION STATEMENT FOR FINANCIAL NEED

 

 

(All information will be verified for authenticity)

 

 

In RE:  ____________________

 

 

AFFIDAVIT

I, _______________________, hereby depose and say that I am personally in need of financial assistance in the amount of $________, and that the facts and information set forth herein are true and correct to the best of my knowledge, and belief and that I take this Affidavit pursuant to the penalties of 18 PA C. S. S 4904 relating to unsworn falsification to authorities:

 

1.  My name, address, phone number, and e-mail address are as follows:

(All information must be supplied)

__________________________

__________________________

__________________________

__________________________

 

2.  I am personally familiar with the witness(es) who have completed exhibit (s) A, (# of exhibit A's attached ___) having known me the Applicant for at least
___ years and ____ months.

 

3.  I have read the Affidavits for Verification and I believe that the statements made by the witnesses therein are true and correct.

 

4.  I the Applicant, _____________, is known to be honest, of good character and competence.

 

5.  ___ I am related by blood ___ or by marriage __ to the Witness (es) _________________________________________________________.

 

6.  The purpose for my request to receive $_________ in Financial Assistance, is to cover the cost of

_______________________________________________________________

_______________________________________________________________.

This financial need occurred when I was

_______________________________________________________________.

 

SWORN TO AND SUBSCRIBED

BEFORE ME THIS_______DAY OF

________________, 200_

 

Respectfully submitted,

_______________________
(Print Name)

_______________________
(Signature)


NOTARY PUBLIC

 

 

 

 

Exhibit B

 

 

ALL EXHIBITS AND FURNISHED INFORMATION WILL BE VERIFIED BY:
CORPORATE SECURITY CONSULTING, Inc.

 

 

Mail all Exhibits after each is notarized with supporting Information to:

Corporate Security Consulting,
P.O. Box 26726
Elkins Park, PA 19027-2902

 

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