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One-Click Financial Hardship Form

Use this form to ask for a waiver of penalty payment while an appeal or extension request is being decided. This is not an Appeal Application Form. Appeal by using the Appeal Application form that is found in this section of the OATH website.

If the Respondent cannot afford to pre-pay the penalty while the Appeals Unit is deciding the appeal, fill out this form.

If Respondent's violation is not dismissed after the appeal is decided, Respondent will still have to pay the penalty.

The request must be submitted with support for your request. Attach copies of financial documents when emailing this form. For example, attach a copy of the first two pages of Respondent's federal tax return for last year.

Submit this form and your documents by clicking the button below

Please read the instructions carefully

* Indicates required fields

Respondent name exactly as it appears on summons:


(If the respondent is an entity, business or corporation, please enter the full name exactly as it is written on the top of the summons using both boxes below. For example, First Name: ABC; Last Name: Corp.)

Name of person completing this form

Does Your Name Appear on the Summons?*

Mailing Address to Receive Determination

If no valid mailing address is provided, this e-form will be invalid and will not be considered by the Hearings Division.

Answer the Questions Below:

You must upload any supporting documentation which you may have (pictures, letters etc.)

Upload .jpeg, .pdf, .doc, files - Total file size cannot exceed 3Mb.

Upload .jpg, .pdf, or .doc file
Upload .jpg, .pdf, or .doc file
Upload .jpg, .pdf, or .doc file

If you have more than 3 documents to upload or the total size of the documents is more than 3 MB, then this One-Click request form may not be the right option for you. You may choose to make your request using the mail-in-form found on the forms section of this website.

If you are a Registered Representative, you must also attach the Registered Representative Authorization form. The Authorization form can be found on the forms section of this website.

Certification

Certification

By clicking the submit button below, I understand that I am signing and filing this application with the OATH Hearings Division. This has the same effect as signing by hand.


Attention users: you should only press the submit button one time.