TOWN OF BEDFORD, NH WELFARE DEPARTMENT APPLICATION FOR ASSISTANCE

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TOWN OF BEDFORD, NH WELFARE DEPARTMENT DATE: APPLICATION FOR ASSISTANCE (COMPLETE THIS APPLICATION IN ITS ENTIRETY BEFORE RETURNING TO THE WELFARE OFFICE) Have you ever applied for Bedford Town

1 TOWN OF BEDFORD, NH WELFARE DEPARTMENT DATE: APPLICATION FOR ASSISTANCE (COMPLETE THIS APPLICATION IN ITS ENTIRETY BEFORE RETURNING TO THE WELFARE OFFICE) Have you ever applied for Bedford Town Welfare before? YES When? I. PRIMARY APPLICANT INFORMATION: Full Name: Social Security Number: Street Address: Date of Birth: Home Telephone: Marital Status: Single Other Phone: Married Spouse/Cohab: Separated/Divorced Spouse/Cohab SS#: Widowed II. HOUSEHOLD MEMBER INFORMATION: LIST EVERYONE WHO LIVES IN THE HOUSEHOLD NAME: RELATIONSHIP: D.O.B.: AGE: SOCIAL SECURITY #: III. OTHER RELATIVES LIST ANY CHILDREN WHO DO T LIVE WITH YOU. INCLUDE CHILDREN OVER 18 YEARS OF AGE. NAME: D.O.B.: Revision: November 2004 Page 1 of 7

2 LIST YOUR PARENTS AND THE PARENTS OF YOUR SPOUSE, ROOMMATE OR COHAB MOTHER: FATHER: PRIMARY APPLICANT SPOUSE, ROOMMATE OR COHAB MOTHER: FATHER: Are your parents or the parents of your spouse, roommate or cohab able to help you financially? YES (If not, please obtain written verification from parents detailing why they are unable to help financially and return such verification to the Bedford Welfare Department.) III. RESIDENCY INFORMATION: LIST YOUR ADDRESS FOR THE LAST TWO YEARS, BEGIN WITH YOUR PRESENT ADDRESS STREET ADDRESS / APT # CITY / STATE FROM (MM/YY) TO (MM/YY) Have you ever applied for or received assistance from any other city, town, or state welfare office? YES Where? When? Under What Name? What type of assistance? Duration of Assistance? RENTAL INFORMATION Landlord s Name: Address: Tel. #: Rental Amount: $ Monthly Weekly Every 2 Weeks Other Are you receiving subsidized housing? If so, what type? How many bedrooms in your apartment? Which utilities are including in your rent? Date rent last paid: Covering Time Period From: To: Have you received an eviction notice? YES Have you ever been to court? YES When? Revision: November 2004 Page 2 of 7

3 IV. EMPLOYMENT HISTORY LIST CURRENT AND LAST TWO (2) EMPLOYERS FOR YOURSELF AND ALL HOUSEHOLD MEMBERS NAME: POSITION: TO/FROM DATES: REASON FOR LEAVING: V. MEDICAL INFORMATION Is anyone in your household unable to work? YES Name: Reason: Is the injury / illness work related? YES Name of Employer: Date claim filed? Doctor s Name: Date able to return to work: List prescribed medications Are you or any other member of the household under a doctor s care? YES Name: Diagnosis: Name: Diagnosis: Doctor s Name and Phone Number: Medications: Doctor s Name and Phone Number: Medications: VI. PROPERTY Do you or any other household member own any real estate? YES Name of Owner: Address of property Mortgage Holder Name/Phone #: Mortgage Payment: $ Date of Last Payment: Foreclosure Pending? YES LIST ALL VEHICLES OF ALL HOUSEHOLD MEMBERS 1. Year Model Plate # Registered to Owned Rented Leased Borrowed Date of Last Payment: Amount of Payment: $ 2. Year Model Plate # Registered to Owned Rented Leased Borrowed Date of Last Payment: Amount of Payment: $ 3. Year Model Plate # Registered to Owned Rented Leased Borrowed Date of Last Payment: Amount of Payment: $ Revision: November 2004 Page 3 of 7

4 LIST ALL ASSETS FOR YOURSELF AND ALL OTHER HOUSEHOLD MEMBERS Do you or any other household members have any bank accounts? YES NAME: NAME OF BANK: CHECKING/SAVINGS ACCOUNT NUMBER: ($) BALANCE (Please provide a copy of your most recent bank statement (s) with this application.) Have your or any other household member closed a bank or credit union account within the last 6 months? YES If so, Who? Which Bank? What type of account? Do you or any other household members have any of the following? If so, write in the $ amount, if not, write N/A. Annuities $ Certificates of Deposit $ Mutual Funds $ Retirement $ Savings Bonds $ Stocks $ Trust Funds $ 401K $ Other $ Do you or any other household member have any insurance policies? YES If so, please list: NAME: NAME OF INSURANCE CO: TYPE OF POLICY: CASH VALUE: Have you or any other household member consulted with an attorney or are working with an attorney regarding a possible lawsuit? If so, provide the attorney s name and address: Reason for lawsuit? Are you or any other household member expecting an inheritance, retroactive disability payment, insurance claim or any lump sum settlement? If so, please explain VII. GENERAL INFORMATION Have you or any member of your household ever been convicted of a felony? YES If so, who? When? Which City / State? Provide details Are you or any other household member presently on parole or probation? YES If so, who? Which City / State? Name of Parole/Probation Officer Provide details Revision: November 2004 Page 4 of 7

5 VIII. INCOME LIST IF YOU OR ANY OTHER HOUSEHOLD MEMBERS HAVE APPLIED FOR, OR ARE CURRENTLY RECEIVING INCOME OR BENEFITS FROM THE FOLLOWING SOURCES: SOURCE: NAME: DATE APPLIED: DATE LAST REC D: AMOUNT: Alimony ANB (Aid Needy Blind) Boarders in Household Cash Available/Set Aside Child Support Disability Insurance Disability State/APTD Disability Employer Employment Wages Food Stamps Fuel Assistance Help from Friends/Relatives Medicaid Old Age Assistance Retirement Pension Severance Pay Social Security - SS Social Sec. Disability SSD SSI (Supplemental Sec. Inc) TANF (Family Assistance) Unemployment Vacation Pay Veteran s Pension WIC (Women/Infant/Children) Workers Compensation Other ARE YOU OR ANY OTHER HOUSEHOLD MEMBERS WORKING WITH ANY OTHER AGENCIES? YES CLIENT NAME: AGENCY NAME/LOCATION: CONTACT PERSON: PHONE NUMBER: Revision: November 2004 Page 5 of 7

6 IX. EXPENSES LIST ALL HOUSEHOLD EXPENSES, DATE LAST PAID AND AMOUNT DUE (must provide complete information) BASIC EXPENSES: AMOUNT: FREQUENCY: DATE LAST PAID: AMOUNT DUE: Rent/Mortgage Food Household/Personal Supplies Heat Electric Prescriptions Basic Telephone Service OTHER EXPENSES: AMOUNT: FREQUENCY: DATE LAST PAID: AMOUNT DUE: Cable Car Payments Court Fees, Fines, Etc. Credit Cards Personal Loans Child Support Payments Insurance Premiums Cellular Phone Membership Dues X. ASSISTANCE REQUESTED LIST THE TYPE OF ASSISTANCE YOU ARE REQUESTING FROM THE TOWN OF BEDFORD (you must be specific your application cannot be processed without a specific assistance request) REASON FOR YOUR REQUEST Revision: November 2004 Page 6 of 7

7 XI. APPLICANT / CO-APPLICANT CERTIFICATIONS READ CAREFULLY BEFORE SIGNING STATEMENT REGARDING CONFIDENTIALITY: Please be advised that the information contained in this application is confidential and privileged and is not considered a public record. Any information furnished will not be published, released or discussed with any individual or agency except when disclosure is required by law or when necessary to carry out the administration of general assistance. ACKWLEDGEMENT/REIMBURSEMENT I/We hereby certify that the information I/We have provided on this application is true and complete to the best of my/our knowledge and belief and provides and accurate summary of my situation, assets, and needs. All information I/We have provided in response to the questions asked by the welfare official is also true and complete to the best of my/our knowledge and belief. I/We understand that I/We may have to provide documents and/or other forms of verification to prove the information requested on the application. I/We agree to repay the Town of Bedford for any assistance granted pursuant to RSA 165:20. Any change in my status must be reported to the Welfare Department within 3 working days and failure to do so may result in termination of my/our assistance. I/We may request a fair hearing if I am/we are not satisfied with any decision regarding my/our assistance; I/We must do so in writing within 5 working days, such request must be returned to the Welfare Department. I/We understand that if I/We knowingly give false information or withhold information related to this application or receipt of assistance, now or in the future, I/We may be prosecuted for a crime. Signature of Applicant Date Signature of Spouse/Co-Applicant Date APPLICANT S AUTHORIZATION TO FURNISH INFORMATION I/We authorize any relative, physician, lawyer, banker, employer, insurance company, mental health professional or any other person or organization having information concerning my/our circumstances to furnish such information to the Bedford Welfare Department. I/We further authorize the Internal Revenue Service, Social Security Administration, any State or County Division of Health and Human Services, Division of Children Youth and Family Services, Division of Adult and Elderly Services, NH Legal Assistance, any City/Town Welfare Department, shelter, Department of Employment Security, Veteran s Administration and Fuel Assistance, or any non-profit agency to release information from their files to the Town of Bedford Welfare Department. A photocopy of this authorization may be used in place of the original. Signature of Applicant Date Signature of Spouse/Co-Applicant Date APPLICANT S RELEASE OF INFORMATION I/We authorize the Town of Bedford Welfare Department to release information as necessary to any State or County Division of Health and Human Services, Division of Children Youth and Family Services, Social Security Administration, Internal Revenue Service, school administration, physician, Fuel Assistance, mental health professional, Division of Adult and Elderly Services, NH Legal Assistance, any City/Town Welfare Department, shelter, Salvation Army, food pantries or any other departments connected with the administration of Welfare. Signature of Applicant Date Signature of Spouse/Co-Applicant Date (Is your application completed in its entirety, including all signatures? If so, please return to the Welfare Department for processing.) Revision: November 2004 Page 7 of 7

APPLICATION FOR ASSISTANCE

TOWN OF FRANCESTOWN APPLICATION FOR ASSISTANCE Date of Application Referred by 1. General Information: Name Date of Birth Address Telephone Social Security number US Citizen? Marital Status Rent or Own?