The Wheeler W.P.A.R.T. Application Process Explained

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1 THE WHEELER W. PRICE MEMORIAL HUNT, INC. The Wheeler W. Price Memorial Hunt, Inc., a 501c(3) entity, was created to honor the memory of Wheeler W. Price, who died January 15, 2014 as the result of Hodgkin s Lymphoma, a form of cancer. In February of 2014 friends of Wheeler organized a pheasant hunt for the benefit of Wheeler s children. The hunt was a huge success and the organizers decided to continue the hunt for the benefit of those persons and their families who are suffering as the result of cancer. As a result, The Wheeler W. Price Memorial Hunt, Inc., a 501c(3) entity was formed. It is governed by a Board of Directors (for a list of Board Members see below). If you or someone you know, who lives in Houston or Dale County, Alabama, is suffering from cancer and he/she and their family is incurring extraordinary expenses such as living expenses, travel expenses, etc., as a result thereof, you may complete the Application below and submit to the address below or to. Your Application will be reviewed by the Board of Directors and you will be advised as to the results. Wheeler was born October 28, 1979 in Dothan, Alabama where he lived his entire life. He was a 1998 graduate of Northview High School and a 2003 graduate of Auburn University where he was a member of Sigma Alpha Epsilon Fraternity. He was employed in management with Cox Pools and later in his career with Bobcat of the Wiregrass. Wheeler was a member of First United Methodist Church. He enjoyed fishing, hunting, and Auburn Football. He especially enjoyed spending time with his children and family. He is the proud father of Wheeler Whitlow Price, Jr., Whit, who was born in May of 2009, and Elizabeth Warner Price, Libby, who joined the family in March of Wheeler was diagnosed with cancer October 22 nd, 2011, at the age of 32. As a result, Wheeler received chemotherapy treatments in Dothan, Alabama and Houston, Texas. Wheeler, Melissa and family moved to Houston, Texas on two different occasions so that Wheeler could receive treatment for the cancer that eventually resulted in his death. As a result, Wheeler and his family realize the financial hardship that results from living away from home, without employment, and enduring a disease such as cancer. PERSONAL INFORMATION: APPLICATION Name of Applicant: Lasts First Middle Age Address: Street (911) and if applicable P. O. Box City: State Zip County Home Phone Work Phone SSN:

2 List other members of household, including children: Name: Relationship: Age: Employer: REQUEST: Amount of Request: of Application: Name/Address/Telephone of person completing form: Please attach your personal statement to: 1) Tell how the funds will be used, and 2) Explain the circumstances that have prompted your need of assistance and proposed resolution. *Please attach appropriate bids/estimates/bills directly relating to your request. EMPLOYMENT INFORMATION: Is applicant currently employed? Yes No Is spouse currently employed? Yes No If not, list last employer and employment dates and please explain why. Gross MONTHLY earnings (include all employed members of the household) Please attach 3 months proof of income. Employer #1 Supervisor: Employer #2 Supervisor:

3 Employment of Others in Household: Name: Employer #1 Supervisor: Employer #2 Supervisor: Monthly Expenses: *HOUSING: All sections marked by * must be accompanied with document *TRANSPORTATION: Mortgage or rent payment: $ Automobile Payments: $ Food: $ Gasoline: $ Tag/Tax: $ *UTILITIES: *INSURANCE: Electricity: $ Medical/Dental/Vision: $ Gas: $ Life/Burial: $ Telephone/Cell Phone: $ Automobile: $ Water/Sewer/Trash: $ Homeowners/Rental: $ Cable/Satellite TV: $ Internet Service: $ Other $ *CREDIT CARDS/CHARGE ACCOUNTS: *LOAN PAYMENTS: (Specify) (Specify) *OTHER EXPENSES: (Specify) *REAL ESTATE TAXES: (Specify) TOTAL MONTHLY EXPENSES:

4 MONTHLY INCOME: Total Gross Earnings for Household $ Alimony $ Bonus, Tips & Commission $ Child Support $ Social Security Benefits $ Food Stamps $ Farm Income $ Other $ Dividends & Interest $ Other $ Real Estate Income $ Other $ TOTAL MONTHLY INCOME: LIABILITIES: *Notes & Payable Mortgage: Lender Name, Address & Phone: Lender Name, Address & Phone: Lender Name, Address & Phone: TOTAL NOTES & MORTGAGES: *Other Debt: (Taxes, Bill, Miscellaneous include address) Attach a list if necessary. Debt #1 $ Debt #2 $ Debt #3 $

5 Debt #4 $ Debt #5 $ Debt #6 $ TOTAL LIABILITIES: *********************************************************************************************** The information contained in this statement is for the purpose of obtaining funding from The Wheeler W. Price Memorial Hunt, Inc. on behalf of the undersigned. Each undersigned understands that the information provided herein is used to consider the request for funding, and each undersigned represents and warrants that the information provided is true and complete and that The Wheeler W. Price Memorial Hunt, Inc., may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Wheeler W. Price Memorial Hunt, Inc. is hereby authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein. Information provided herein shall be deemed confidential. Signature of Applicant Signature of Spouse/Co-Applicant The Wheeler W. Price Memorial Hunt, Inc. is hereby authorized to utilize applicants name/organization for promotional or communication purposes (i.e. annual reports, news/press releases, brochures, etc.). Signature of Applicant Mail completed application and related documents to: The Wheeler W. Price Memorial Hunt, Inc. (Insert Address) BOARD OF DIRECTORS Melissa W. Price Edward M. Price, Jr. Joel Hewes George Flowers Ricky Ball Martin Price, III Archie Solomon C. K. Merrill Whit Hewes