Simply copy and paste the application below to a new Word document or Notepad.  Fill in your information, print it out and send your completed application form to:

Mike Bell, Dir. of Assistance
509 Joyner Road
Waynesboro, GA   30830

Hunters Helping Hunters

509 Joyner Rd.

Waynesboro, GA 30830

http://www.hhh-usa.org

Name ________________________Phone number ( ) _______________

Address: _______________________ City ____________ State ___ Zip ________

Your E-mail address (optional) ______________ Age _____ Date of Birth ___/ ___/___

Did you hunt last year? YES or NO If no, last year you hunted _____

Which state issued your license? _______________ Date issued:____________

Please supply license Number: ____________________

If available, please attach at photocopy of your hunter.s license.

How did you hear about Hunters Helping Hunters (HHH)?

______________________________________________________________________________

Why are you requesting financial assistance?

Did the police, an Insurance Agency, or similar agency investigate this incident, which created

this need? _________ If so, state Agency.s name and address

(If there is a copy of a Police incident. / accident report, please attach a copy)

As a result of this incident, did you or your family suffer any financial loss or burden? Explain:

Please explain or fully describe your situation and how any loss occurred.( use additional sheets if

necessary)

Amount of assistance requested $ __________. 00, from Hunters Helping Hunters

If granted, how is this assistance in full or part going to be used?

To whom will the assistance go?

(Cash payment will not be made directly to any applicant, only to creditors or businesses deemed owing)

Attach copies of bills, estimates, or other proof of indebtedness.

Are you currently employed? ______ If so, Employer ____________________

Address of employer ______________________Phone Number ______________

Number of years employed? _________Average monthly earnings $ _______.00.

Is the person out of work as a result of this situation? ______

Last date of work if currently unemployed: ___/____/___

Return date to wok, if known: ___/___/___

Was this loss or incident covered by any insurance ________ if yes, type of insurance and

Name of carrier _____________________________________________________

Are you collecting or have you applied for any other form of assistance? _________

If yes, Name of Assistance and dollar amount of Assistance

_____________________________________________________________________

Is there any pending litigation over this incident, or have you been in contact with an attorney

____________if yes, give name, address and phone number?

_____________________________________________________________________

Do you own your own home? ____ if so, number of years remaining on loan? ____

Monthly mortgage or rent payment_____________

If renting or leasing home list Landlord name, address, and telephone number

_______________________________________________________________________

How long have you lived in current residence? __________Years

Do you own a vehicle? ________If yes, list year, type and model of all vehicles

______________________________________________________________________________

Total monthly car payment? _______

Total cost of Monthly Utilities (electric, gas, water, sewer) ______________

Do you have a checking account? ________ Total Balance_$________. 00

Do you have a saving account? _______ Total Balance_$________. 00

Name and address of Bank _______________________________________________________

Do you own a Credit Card?______, if so list all credit card (Visa, Master Card)

________________________________________________________________________

Total amount of Monthly Credit Card bill? $ ________

I ______________________________________hereby authorize the members, committees,

board members and employees of ( HHH ) to fully investigate all information I have supplied in

the pervious pages, which are in accordance with my request for financial assistance.

Furthermore in signing this waiver, I authorize Hunters Helping Hunters to obtain my personal

financial information, verification of employment, verification of my loss and any other

information they, HHH, may deem necessary in order to process and investigate my request. In

addition, I agree to hold harmless Hunting Helping Hunters (HHH) it employees, members of the

board of directors, its membership or committees, jointly and severely from any action or form

of action arising out of my applying for assistance through Hunters Helping Hunters HHH). I

also agree to hold harmless any institution or person supplying Hunters Helping Hunters with

information pertaining to this request.

I fully understand that this application may be granted or denied at any time with or without

Cause by the board of directors of Hunters Helping Hunters (HHH).

In signing this release of information and waiver, I swear that the facts contained in the previous

pages are true and correct to be best of my knowledge and recollection. I am also aware that

swearing to false statements could make me guilty of a crime.

______________________________

( signature )

____________________________________

(date)

Hunters Helping Hunters, Inc, hereby agrees that all information contained in this

application and resulting investigation shall remain confidential. All information will be

solely used for official HHH business.