Please print this form and fax or mail:

U-Haul Communities of Hope Foundation

Request For Financial Assistance

Please note: The level of funding assistance may vary based on the request and the availability of funds at the time the application is received.

Organization's name:_______________________________________________________

Contact Person:___________________________________________________________

Address:_________________________________________________________________

City:_____________________________Province:_________Postal Code_____________

Telephone Number:_________________________E-mail Address___________________

Cause/Mission_________________________________________________________________

Have you previously received funding from us? YES________ NO________

Reason for Funding:

Amount requested: _____________________

Who does this help?__________________________________________________________________

Other funding sources you have requested or receive?

Please explain:______________________________________________________________________ _________________________________________________________________________________

Waiver: I will indemnify and save harmless U-Haul Communities of Hope Foundation and it's employees from and against any and all expenses related to all claims, demands, liabilities, losses, costs, damages, actions, suits or other proceedings of any nature or kind whomsoever sustained,brought or prosecuted in any manner whatsoever, including without limitation based upon, occasioned by or attributed to the negligent act or omissions or the willful or reckless misconduct of the organization, in the fulfillment of utilizing the funds provided by U-Haul Communities of hope Foundation.

Certification:

I certify that the information provided in this application is true, correct and complete to the best of my knowledge.

Organization's Signature:____________________________________Date:_____________________