DELPHI SALARIED RETIREE ASSOCIATION



DelPhI SALARIED RETIREES ASSOCIATION BENEFIT TRUST

Voluntary Employee Beneficiary Association (VEBA)

Hardship Award Application for 2010

Hardship awards shall only be used toward direct payment of health care insurance for eligible Delphi retirees and dependents. We are unable to make payment on specific medical or pharmacy bills. Award eligibility is based primarily on financial status relative to the federal poverty levels.

A committee appointed by the VEBA Board of Directors – known as the Hardship Award Committee - reviews all applications and reserves the right to request additional information as needed. Funds will be awarded on a case-by case basis. All information is confidential.

Instructions: INCOMPLETE APPICATIONS CANNOT BE PROCESSED

(1) Fill in ALL information requested on this Application Form.

(2) You MUST include a copy of:

(a) your 2009 year Federal Tax Return (both returns for those filing separately) or, if not yet filed for the current year, the previous year’s Federal Tax Return

(b) your most recent health care insurance invoice

(c) retirement pay stub(s) for you and your spouse or domestic partner

(d) employment pay stub(s) for you and your spouse or domestic partner

(3) Fill out and sign (retiree and spouse or domestic partner) the Declaration of Assets Form (Page 4)

|Applicant Information |

|Last Name | |First: | |M.I. |Birth | |

|(circle one: Mr./Mrs./Ms.) | | | | |Date | |

|Street Address: | |Apartment/Unit # | |

|City: | |State: | |ZIP | |

|Phone: | |E-mail Address | |

|Mobile Phone: | |Retirement Date (month| | | |

| | |& year): | | | |

|May we leave a message on your home phone? | May we leave a message with your spouse or domestic partner? YES NO | |

|YES NO phone? | | |

|Are you able to work? |Explain: |

|Are you Medicare eligible? |YES |NO | Eligible for Social Security? |YES |NO |

|Medicare Part A? YES NO Part B? |YES |NO |If yes, explain:| |

|Eligible for or Receiving Social Security ? |YES |NO | | |

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|ADDITiONAL FINANCIAL Assistance |

|Have you received any other financial assistance? If yes, please provide dates, assistance received and name of agency or provider. |

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|OTHER ASSISTANCE |

|Have you contacted any other local, state, or federal agencies for assistance? If yes, please provide dates, assistance received and name of provider. |

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In the event that your answer does not fit into the space provided on this Application and Financial Disclosure Request, you may attach additional pages

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Financial Disclosure

Section 1. – Retiree and Dependants

|Name: |

|Address: |

|Name & Birth Date of Spouse/Domestic Partner: |

|Name(s) and Birth Date(s) of Dependants: |

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Section 2. – Monthly Income & Deductions

|Average Household Monthly Income & Deductions |Household |

|1. Monthly income (before any deductions) | |

|A. Monthly pension check income |$ |

|B. Monthly social security, VA benefits |$ |

|C. Any net business income |$ |

|D. All other sources of income |$ |

| |$ |

| |$ |

|2. Total Monthly Household Income (items 1A, 1B, 1C and 1D) |$ |

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Section 3. - Medical Expenses

|Average Monthly Medical Insurance Expenses |Household |

|3. Monthly health care and/or prescription drug insurance premiums |$ |

|4. Provider | |

Section 4. – Assets

|5. Cash in bank (checking, savings accounts, etc.,) |$ |

|6. Cash on hand |$ |

|7. 401k and IRA Accounts, etc. |$ |

|8. Other Assets (including income producing real estate, trust funds, annuities, etc)|$ |

|9. Stocks, Bonds, Investments (current total value) |$ |

|10. Real Estate Owned (resale values, ) |$ |

|11. Rental units net income |$ |

Section 5. - Additional Data

|12. Have you ever been adjudicated Bankrupt? If so and VA or a mortgage company was involved please send all pertinent |

|documentation. |

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|13. Date Discharged from Bankruptcy. (MM-DD-YYYY) |

|14. Use this space to supply additional information and to continue your answers to previous items to which your comments apply. |

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|15. Use this space to provide any other information you wish to be considered with respect to your financial condition and/or |

|relating to any dependants for whom you are financially responsible. |

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DECLARATION OF ASSETS

To: Delphi Salaried Retirees Benefit Trust,

Attention of Hardship Award Committee

From:

Retiree’s Printed Name:______________________________________________________

Spouse’s or Domestic Partner’s Printed Name:___________________________________

(circle one)

We, the undersigned, declare that our VEBA Hardship Award Application accurately represents our current financial condition and that we have no additional income or financial assets (including cash, accounts such as checking, savings, money markets, IRA, 401k, 403b, CD, stocks and bonds, other forms of investments including such as precious metals, etc.).

By executing the above Declaration, I/we represent and warrant that all information reflected herein is accurate to the best of my/our knowledge.  I/we understand that the information being provided by and through this Declaration will be relied upon the Delphi Salaried Retirees Benefit Trust to make a determination of Hardship Award eligibility and that any intentional misrepresentation made herein may be actionable at law.

 

Signed,

___________________________________ Date: ___________

Retiree

___________________________________ Date: ___________

Spouse or Domestic Partner (Circle one)

Mail your completed application to:

Delphi Salaried Retirees Association

c/o The UPS Store

10051 E. Highland Road. STE 29-268

Howell, MI 48843-6317

CHECKLIST – HAVE YOU INCLUDED ?

√ when completed

(1) THE COMPLETED APPLICATION FORM

(2) 2009 FEDERAL TAX RETURN(S) – BOTH IF FILING SEPARATELY

PLEASE BLACK OUT ALL SOCIAL SECURITY NUMBERS

(3) YOUR HEALTH CARE INSURANCE INVOICE

(4) RETIREMENT PENSION STUB(S) FOR THE HOUSEHOLD

(5) EMPLOYMENT PAY STUB(S) FOR THE HOUSEHOLD

(6) THE SIGNED DECLARATION OF ASSETS

REMEMBER: INCOMPLETE APPLICATION PACKETS

CANNOT BE PROCESSED

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