Page 1
TOWN OF STRATHAM
APPLICATION FOR ASSISTANCE
Date of Application ______________________
1. General Information:
Name _____________________________________________ Date of Birth____________Age____
Current Address ______________________________________________________________________
Telephone_____________________ SS# _______________________________ US Citizen? ______
Marital Status________________________Date of Marriage/Divorce__________________________
Spouse/Co-Applicant Name__________________________ Date of Birth_____________Age_____
Spouse address (if not same as applicant) __________________________________________________
Telephone_____________________SS#_________________________________US Citizen?______
Assistance Requested_______________________________________________________________
Reason for request ____________________________________________________________________
Have you ever received any kind of public assistance before? __________ When?________________
Where? ____________________________________________ Amount $______________________
List below all persons living in your household including yourself:
Full Name Relationship Date of Birth Age
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
List all addresses for past two years starting with most recent:
Street Town/City State Dates of Residence
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
____________________ ____________________ ________________ ___________________
Page 2
2. Housing Information:
Rent or Own? _______________ How long at this address?______________________
Rent amount ___________per (month/week) Date last paid________________ Date due __________
Do you have a current: Demand For Rent  Eviction Notice  Landlord/Tenant Writ
Total rent owed ___________________ Do you have a housing subsidy? ____________
Utilities Included:
Heat Electric Gas Water/Sewer Other None
Do you have a current shut off notice for any utilities?_____ If so, which utilities?________________
LANDLORD: Name _________________________________ Telephone________________________
Address__________________________________SS # (
only if seeking rental assistance)______________
IF HOME-OWNER: Mortgage Amount (including insurance and taxes) $________________________
Date last paid________Date Due_________Owed___________Bank/Mortgage Co.______________
3. Education / Training / Employment
Highest Grade G.E.D. or Military
Attended Diploma Special Training or Skills Service
Applicant: _____________ ________ _________________________ __________
Spouse/Co-Applicant: _____________ ________ _________________________ __________
Applicant Work History:
Are you employed now? _______Employer_____________________Avg. Weekly Wage_________
When began work___________Date/Amt of most recent check__________ Position______________
Are you unemployed now? __________ Reason_______________Date last worked________________
Employer______________________Date/Amount last check____________Position______________
Are you able to work now? ________If not able, why? _______________________________________
Spouse/Co-Applicant Work History:
Are you employed now? _______Employer_____________________Avg. Weekly Wage_________
When began work___________Date/Amt of most recent check__________ Position______________
Are you unemployed now? __________ Reason_______________Date last worked________________
Employer______________________Date/Amount last check____________Position______________
Are you able to work now? ________If not able, why? _______________________________________
Page 3
List work history for last 2 years of yourself and all household members aged 18 & older:
Employment Reason for
Name Employer Weekly Pay Dates Leaving
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. Household Assets:
Provide information regarding bank accounts held by you and all household members:
Savings
Savings Checking Checking
Name Bank/Credit Union Acct. # Balance Acct. # Balance
____________ ________________ __________ __________ __________ _______________
____________ ________________ __________ __________ __________ _______________
____________ ________________ __________ __________ __________ _______________
____________ ________________ __________ __________ __________ _______________
Provide current value of any assets held by you and all household members:
Cash on hand (all household combined) ______________ Certificates of Deposit (CD’s)____________
Stocks/Bonds/Securities____________Trust Funds______________Retirement Accounts ___________
Insurance Policies (cash value)_____________401k ____________ Other Investments______________
Real estate (other than listed in Section #2) _______________________________________________
Motorcycles/Boats/Snowmobiles/ATV’s/RV’s____________________________________________
__________________________________________________________________________________
Other Assets (please list) _______________________________________________________________
Claims/settlements/income due to you or any household member
IRS Refund___________ Insurance Claim _____________ Retroactive disability check_____________
Retroactive Unemployment or Worker’s Compensation check______________ Inheritance__________
Other Lump Sum Payment (explain) ______________________________________________________
Do you or any household member have a lawsuit pending? _______ Who? ____________________
Please give details ____________________________________________________________________
Lawyer Name/Address_________________________________________________________________
Page 4
Motor vehicles owned by you and all household members:
Owner Auto Make Model Year Payments Insurance
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. Household Income
Indicate any benefits or income received or applied for by you or any household member (check
all those that apply):
Date Date Last Monthly
Applied Received Amount
Child Support ___________ __________ ____________
Disability ___________ __________ ____________
Food Stamps ___________ __________ ____________
Fuel Assistance ___________ __________ ____________
Income from relatives/boarders ___________ __________ ____________
Medicaid ___________ __________ ____________
OAA (Old Age Assistance) ___________ __________ ____________
Pension ___________ __________ ____________
Retirement ___________ __________ ____________
Severance Pay ___________ __________ ____________
Social Security ___________ __________ ____________
SSI (Supplemental Security) ___________ __________ ____________
TANF ___________ __________ ____________
Unemployment ___________ __________ ____________
Veteran’s Benefits/Pension ___________ __________ ____________
WIC (Women/Infants/Children) ___________ __________ ____________
Worker’s Compensation ___________ __________ ____________
Other: [ ] ___________ __________ ____________
Page 5
6. Household Expenses
List actual or estimated regular monthly expenses. (Not all expenses will be allowable to be
included in your eligibility determination, but all should be listed to show your financial situation.)
Bank Fees______________________ Mortgage/Rent______________________
Electric________________________ Prescriptions________________________
Cable/Internet___________________ Food______________________________
Child Support Paid_______________ Heat______________________________
Car Gasoline____________________ School Loan________________________
Car Insurance___________________ Storage Unit________________________
Car Payment____________________ Health Insurance_____________________
Condo Fee______________________ Child Care__________________________
Credit Card_____________________ Telephone__________________________
Medical Co-Pays_________________ Transportation_______________________
Other__________________________ Other_____________________________
List unplanned, emergency or irregular periodic expenses during the past 30 days:
Car Inspection _____________ Drivers License ________________ Medical ____________________
Car Registration ____________ Fines/Court Payments ___________ Tax (Income/Property)_______
Car Repair ________________ Home Repairs _________________ Other____________________
Dental____________________ Home/Rent Insurance ___________ Other ______________________
7. Criminal Information
Have you or any member of your household ever been convicted of a felony? _____________________
If yes, who? ________________When?____________Town/City & State of conviction___________
Details of conviction:________________________ Charges Annulled?______ If yes, when?_______
Are you or any member of your household presently on parole or probation? _____________________
If yes, who?_________Name & phone # of parole/probation officer _____________________________
8. Liability for Support Information in Accordance w
ith RSA 165:19
Please provide the following details:
Your father_________________Address____________________________ Own real estate?_______
Your mother________________Address____________________________ Own real estate?_______
Co-App. father______________Address____________________________ Own real estate?_______
Co-App. mother_____________Address____________________________ Own real estate?_______
Page 6
9. Certifications and Signatures
I hereby certify that the information I have provided on this application is true and complete to the best of
my knowledge and belief and provides a true summary of my income, assets and needs. I understand I
may be required to provide documents and/or other forms of verification to prove the information
requested on this application. I hereby certify that all information I will provide in response to questions
asked by the welfare official is true and complete to the best of my knowledge and belief. I understand
that if I knowingly give false information or withhold information related to my receipt of assistance, now
or in the future, I may be prosecuted for the crime of Unsworn Falsification (RSA 641:3).
I understand that if I obtain a job after I am assisted by the municipality, and I later quit the job without
good cause, I may be ineligible for local assistance from the municipality and any other New Hampshire
municipality for a period of up to ninety days (RSA 165:1-d).
I understand that if I am a recipient of Temporary Assistance for Needy Families (TANF) cash benefits
and I fail to comply with TANF regulations, leading to a sanction and loss of income, the municipality
may, under certain circumstances, disregard this decrease in my income (RSA 165:1-e).
______________________ _________ _____________________ ___________
Applicant Signature Date Spouse/Co-Applicant Signature Date
REIMBURSEMENT AGREEMENT
I acknowledge that I may be required to repay any assistance provided if I am returned to an income
status which enables me to reimburse the Town without financial hardship.
_____________________________ ______________________________
Signature of Applicant Spouse/Co-Applicant
I agree that if I have a lawsuit, other outstanding settlement, or aid from any other social services agency
now pending disposition, I will list the name, address, and phone number of my attorney, insurance
company, or any other agency which may be handling this claim on my behalf. I further agree to notify
the Welfare Official immediately upon the receipt of any money from such claim or upon the settlement
of such claim.
Name___________________________ Name________________________
Address_________________________ Address_______________________
________________________________ _____________________________
Phone___________________________ Phone_________________________
_________________________ __________ _______________________ __________
Signature of Applicant Date Spouse/Co-Applicant Date
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 7
INFORMATION RELEASE
I understand that as part of the administration of this program, the Town may verify information I have
provided on the application and any other information that would affect my eligibility. My signature
below authorizes the Town to obtain verification from any person or organization having information
concerning my circumstances, including any relative, physician, lawyer, banker, employer, or insurance
company, and authorizes the release of such information to the Town. A photocopy of this signed release
may be used in place of an original.
______________________________________ ____________________
Applicant Signature Date
______________________________________ ____________________
Spouse or Co-applicant Signature Date
______________________________________ ____________________
Witness to all Signatures Contained Therein Date
______________________________________
Valid ID Provided
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
TITLE XII
PUBLIC SAFETY AND WELFARE
CHAPTER 165
AID TO ASSISTED PERSONS
Liability for Support, and Recovery Over
Section 165:19
165:19 Liability for Support. – The relation of any poor person in the line of father, mother,
stepfather, stepmother, son, daughter, husband, or wife shall assist or maintain such person when
in need of relief. Said relation shall be deemed able to assist such person if his weekly income is
more than sufficient to provide a reasonable subsistence compatible with decency and health.
Should a relation refuse to render such aid when requested to do so by a county commissioner,
selectman, or overseer of public welfare, such person or persons shall upon complaint of one of
these officials be summoned to appear in court. If, after hearing, it is found that the alleged poor
person is in need of assistance, and that the relation is able to render such assistance, the court
shall enter a decree accordingly and shall fix the amount and character of the assistance which
the relation shall furnish. If the relation neglects or refuses to comply with the court order
without good cause, as determined by the court at a hearing, or by refusing to work or otherwise
voluntarily places himself in a position where he is unable to comply, he shall be deemed to be in
contempt of court and shall be imprisoned not more than 90 nor fewer than 60 days. If a poor
person has no relation of sufficient ability, the town or city in which he resides shall be liable for
his support.
Source. RS 66:8. CS 70:8. GS 74:8. GL 82:8. PS 84:12. 1925, 112:1. PL 106:22. 1933, 65:1. RL
124:18. RSA 165:19. 1973, 115:1. 1985, 380:11, eff. Jan. 1, 1986.
REQUIRED VERIFICATIONS
Applicant Name: _____________________ DOB:_______________DATE:_____________
Address: ___________________________ Phone: _______________________________ _
You must provide the following verification/documentation to the Town or
assistance may be delayed or denied:
Completed Application Form
Rental Verification Form / Lease
Divorce decree, if applicable
Last four week’s pay-stubs or other proof of net wages
Last four week’s receipts or other proof of bills paid or currently due
Employment verification form from your employer
Employment termination form from your last employer
Registration forms from Department of Employment Security
You have applied for / are receiving Social Security benefits
You have applied at the HHS District Office for:
Food Stamps TANF APTD/MA OAA
You have applied for / are receiving Fuel Assistance benefits
Verification of injury or illness (doctor’s note)
You have applied for / are receiving Unemployment Compensation
Picture ID (adults); Birth certificate/SS card (minors)
Vehicle registration(s)
Savings and checking account, liquid asset statements, bankbooks
Statement child support payments received / Child support court order
Statement from roommate(s) regarding division of expense
Termination notice from previous welfare (state, city or county welfare) agency
Any shut off notices, notice to quit, demand for rent, etc.
Other: ___________________________________________________________________________
NOTE: Photocopies will be taken of the above documentation during your appointment.
I understand that failure to provide the indicated information may result in delay and/or denial of my
request for assistance, and I understand that if approved for assistance, I may be required to do a job
search and participate in workfare.
______________________________ _______________________________
Applicant Witness
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome