Primary Guarantor Financial Application

Name of Person Completing Form

Enter your full name.

This field is required.

Name of Secondary Guarantor (if different)

Enter the full name of the secondary guarantor, if applicable.

This field is required.

Name of Resident

Enter the full name of the resident.

This field is required.

Email Address

Enter a valid email address.

This field is required.

Home Address

Enter the guarantor’s complete home address.

Address Line 1

This field is required.

Address Line 2

This field is required.

City

This field is required.

State

This field is required.

Postal Code

This field is required.

Country

Phone Number

Enter your phone number including area code.

This field is required.

Social Security Number

Enter your Social Security Number (XXX-XX-XXXX).

This field is required.

Driver’s License Number

Enter your Driver’s License Number.

This field is required.

Scholarship Award Amount

Enter the awarded scholarship amount.

This field is required.

Remainder of the $9000 fee

This is the remaining fee amount after scholarship.

This field is required.

I agree to pay the first month’s fees by this date

(Usually on the date the resident comes to Recovering Hands).

This field is required.

I agree to pay the Second month’s fees by this date

(Usually prior to the first day of her Second Month).

This field is required.

I agree to pay the Third month’s fees by this date

(Usually prior to the first day of her Third Month).

This field is required.

Payment Method

Select your preferred payment method.

This field is required.

Agreement to Underwrite Fees of the Resident

I agree to underwrite the fees of the resident listed above.

This field is required.