Application for Assistance.

Please fill out the Application for Assistance form as well as the W-9 form to apply for financial assistance from HLS Charities.* To meet tax requirements, a W-9 form must be filled out and submitted with each application for assistance. Click here to download the pdf version of the W-9 Form. All W-9 Forms should be emailed to gary@hlscharities.com

* Employees of Hi-Line Supply, Inc. or applicants related to any current board members are not allowed to participate in the HLS Charities application process or to receive benefits from this charity.

Applicant for Beneficiary's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Is either parent currently employed?

Parent's Name

First Name

Last Name

Parent's Name

First Name

Last Name

Child's Name

First Name

Last Name

Child's Age

Child's Name

First Name

Last Name

Child's Age

Child's Name

First Name

Last Name

Child's Age

Name of Patient

First Name

Last Name

Diagnosis of Illness

List "Immediate" needs beginning with the most important to the least:

Please provide a brief description of why you are requesting assistance from HLS Charities

Please let us know how you heard of HLS Charities

Would you be interested in promoting HLS Charities in the future?

Yes

Applicant for Beneficiary's Signature

By typing your name you assert all information is true and accurate. Please email W-9 form to gary@hlscharities.com.

First Name

Last Name

Date

YYYY