Debt Hardship Program Application
Applicant Name
*
First Name
Last Name
Applicant Email
*
example@example.com
Applicant Date of Birth
*
-
Month
-
Day
Year
Date
Applicant Legal Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My Total Annual household income is at or below the following:
*
80% of median local income
200% of poverty level
My household size for 2025 was:
*
My total household income for 2025 was:
*
Attach prior year's state or federal tax return or paycheck stub (dated within the last 90 days) below.
Acknowledgement:
I, the undersigned, acknowledge that the data submitted in this application is a true and accurate representation as of the date of this application.
I have not applied for the City of Peoria's Debt Hardship Program for debt forgiveness before.
I understand that if I qualify for partial forgiveness of debt, I will have to enroll in a payment plan for the remaining debt and my failure to make all required payments will result in my disqualification from the program and the reinstitution of the entire debt owed.
I understand that the City of Peoria will evaluate my application to determine my debt forgiveness eligibility.
I understand that I may submit a written request for appeal of any denial of eligibility to the City Manager.
Applicant Signature
*
Income Verification Document(s)
*
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Attach prior year's state or federal tax return or paycheck stub (dated within the last 90 days)
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