HALO Club Request Form

A Request Form is required for consideration. All fields are required – incomplete forms may be rejected.

The HALO Club offers financial assistance to the following groups:

• Residents of the Omaha/Council Bluffs metropolitan area
• All current employees or retirees of Mutual of Omaha, regardless of geographic location

Please note that the HALO Club does not provide assistance through the payment of deposits of any kind, including rental or utility deposits.

Personal Information

Name	Address
City	State/Zip   AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA VI WA DC WV WI WY
Phone (xxx-xxx-xxxx)	Best Time to Reach You

Your Name and Contact Information (if filling out for a client)

Name and Ages of Adults and Children Living at Home

List Amounts of All Monthly Bills

Gas & Water $	Car Payment $	Electricity $
Cable Television $	Phone $	Child Care $
Rent $	Insurance $	Food $
Medical $

Landlord Name and Number

Miscellaneous (Please List)

Total Bills $

Sources of Income

Currently Employed? Yes   No

Employer

How long?

If Unemployed:

How Long?

Reason for Unemployment?

Net Monthly Income $

Spouse Currently Employed? Yes   No

Employer

How long?

If Unemployed:

How Long?

Reason for Unemployment?

Spouse’s Net Monthly Income $

Please List Monthly Amounts of All That Apply

Retirement $	Child Support $	Government Assistance $
Aid to Dependent Children (ADC) $	Social Security $	Disability $
Food Stamps $	WIC $

Miscellaneous (Please List)

Total Income $

Assistance

Item Requested

Cost: $

Describe reason for making this request

Other Agencies Contacted