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HALO Club Request Form

A Request Form is required for consideration.
ALL FIELDS ARE REQUIRED - INCOMPLETE FORMS MAY BE REJECTED.

The HALO Club offers financial assistance to the following groups:

  • Residents of the Omaha/Council Bluffs metropolitan area
  • All current employees or retirees of Mutual of Omaha, regardless of geographic location
Please note that the HALO Club does not provide assistance through the payment of deposits of any kind, including rental or utility deposits.

Personal Information
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(xxx-xxx-xxxx)

List Amounts of All Monthly Bills
$ $
$ $
$ $
$ $
$ $
$
Sources of Income
Yes
No
   
$
 
Yes
No
   
$
Please List Monthly Amounts of All That Apply
$ $
$ $
$ $
$ $
$
Assistance
  $
  

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