Fillable Town of Hudson Application for Assistance (Town of Hudson)

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Town of Hudson Application for Assistance (Town of Hudson)

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Town of Hudson
Application for Assistance
Please call Kathy Wilson at (603) 595-6518 for an
Appointment after application is completed.
Town of Hudson
REQUIRED VERIFICATIONS
Applicant Name:______________________ Date: _________________________________
Social Security Number: _______________ D.O.B.: _______________________________
Address: ____________________________ Phone: ________________________________
You must provide the following verification/documentation at the time of your appointment
or assistance may be delayed or denied:
_____ Completed Application Form
______ Rental Verification Form
______ Last four weeks 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
_____ You have applied for / are receiving Social Security benefits
_____ You have applied at the DHHS District Office (883-7726) for:
Emergency Food Stamps Food Stamps TANF
Title XX Daycare APTD/MA OAA
TANF Emergency Assistance
_____ You have applied for / are receiving Fuel Assistance benefits
_____ Verification of injury or illness
_____ You have applied for / are receiving Unemployment Compensation
_____ Proof of Identification / Picture ID (adults); Birth certificate/SS card (adults & minors)
_____ Vehicle registration
_____ Savings and checking account, liquid asset statements, bankbooks
_____ Statement child support payments received / Child support court order
_____ Statement from room-mate(s) regarding division of expenses
Other: ____________________________________________________________
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.
_________________________________________ ____________________________________
Town of Hudson signature Applicant signature
TOWN OF HUDSON
APPLICATION FOR ASSISTANCE
HUDSON, NEW
12 SCHOOL STREET HUDSON, NEW HAMPSHIRE 03051 (603) 595-6518
Date of Application_____________________________ Referred by______________________________________________
1. General Information
:
Name _______________________________________________________ Date of Birth ___________________________
Address ____________________________________________________________________________________________
Telephone __________________________ Social Security number ______________________ US Citizen? ___________
Marital Status ________________ Rent or Own? __________________ How long at this address? ___________________
Spouse/Co-Applicant Name ___________________________________ SS#_____________________________________
Spouse address (if not same as applicant) __________________________________________________________________
Assistance Requested _________________________________________
Reason for request____________________________________________________________________________________
Have you applied for local assistance before? _______________________ When? ________________________________
Where? _____________________________________________________ Under what name? ______________________
Amount? __________________________
List below all persons living in your household:
Full Name Relationship Date of Birth Social Security #
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
If at your current address less than 12 months, please list past 12 month’s addresses:
Street Town/City State Dates of Residence
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
________________________ ________________________ ___________________ ______________________
2. Housing Information:
Rent amount per (month/week) Date last paid Date due
Do you have a current:
Demand for Rent  Notice to Quit  Landlord/Tenant Writ
Total rent owed __________________________ Do you have a housing subsidy? ___________________
Utilities Included:
Heat  Electric  Gas  Water/Sewer  Other
LANDLORD: Name ___________________________________________ Telephone______________________________
Address ____________________________________________________________________________________________
IF HOME-OWNER: Mortgage Amount ____________________ Date last paid ________________ Owed____________
Bank/Mortgage Co _____________________________________ Address_______________________________________
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_____________________________ Position _____________________
When began work ________________________Date/Amount of most recent check________________________________
Are you unemployed now? _________________Reason______________________________________________________
Date last worked _______________ Employer _______________________ Date/Amount last check _________________
Are you able to work now? ______________ If not able, why not? _____________________________________________
Spouse Work History:
Are you employed now? ____________ Employer_____________________________ Position _____________________
When began work ________________________Date/Amount of most recent check________________________________
Are you unemployed now? _________________Reason______________________________________________________
Date last worked _______________ Employer _______________________ Date/Amount last check _________________
Are you able to work now? ______________ If not able, why not? _____________________________________________
Current and two most recent jobs of yourself and all household members aged 18 & older:
Weekly/
Employment Reason for
Name
Employer Pay Biweekly Dates Leaving
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
___________________ ___________ _______ ______________ ______________ ________________________
4. Household Assets:
Provide information regarding 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) __________________
Savings Bonds________________ Mutual Funds________________ Annuities ____________ Stocks _______________
Trust Funds _____________ Retirement Accounts _______________ Insurance Policies (cash value) _________________
401k ______ Property other than primary residence __________________________ Location______________________
Other Investments ______________________ 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)______________________________________________________________________
Have you or any household member consulted a lawyer regarding a possible lawsuit?:
Lawyer Name/Address ________________________________________________________________________________
Reason _____________________________________________________________________________________________
Do you or any household member have a lawsuit pending? ___________________ Who? ________________________
Please give details ____________________________________________________________________________________
Lawyer Name/Address ________________________________________________________________________________
Motor vehicles owned by you and all household members:
Owner
Auto Make Model Year Value Payments Insurance
______________ _______________ ___________ __________ ___________ ____________ _______________
______________ _______________ ___________ __________ ___________ ____________ _______________
______________ _______________ ___________ __________ ___________ ____________ _______________
5. Household Income
Indicate any benefits or income received or applied for by you or any household member:
Name Date Date Last Monthly
Applied Received Amount
ANB (Aid to the Needy Blind) ___________________ ____________ _______________ ________________
APTD ___________________ ____________ _______________ ________________
Child Support ___________________ ____________ _______________ ________________
Disability (Employer) ___________________ ____________ _______________ ________________
Food Stamps ___________________ ____________ _______________ ________________
Fuel Assistance ___________________ ____________ _______________ ________________
Gifts/Loans ___________________ ____________ _______________ ________________
Maternity Benefits ___________________ ____________ _______________ ________________
Medicaid ___________________ ____________ _______________ ________________
OAA (Old Age Assistance) ___________________ ____________ _______________ ________________
Retirement ___________________ ____________ _______________ ________________
Severance Pay ___________________ ____________ _______________ ________________
Social Security ___________________ ____________ _______________ ________________
SSDI (SS Disability) ___________________ ____________ _______________ ________________
SSI (Supplemental Security) ___________________ ____________ _______________ ________________
TANF ___________________ ____________ _______________ ________________
Unemployment ___________________ ____________ _______________ ________________
Vacation Pay ___________________ ____________ _______________ ________________
Veteran’s Pension ___________________ ____________ _______________ ________________
Vocational Rehabilitation ___________________ ____________ _______________ ________________
WIC(Women/Infants/Children) ___________________ ____________ _______________ ________________
Worker’s Compensation ___________________ ____________ _______________ ________________
Other: [ ] ___________________ ___________ _______________ ________________
Are you or any other household member working, volunteering, and/or receiving assistance from any other agencies?
Name
Agency Name Contact Person
___________________________________ __________________________________ _________________________
___________________________________ __________________________________ _________________________
___________________________________ __________________________________ _________________________
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 ______________________Diapers ____________________________ Mortgage ________________________
Bus/Cab________________________Electric ____________________________ Prescriptions______________________
Cable/Internet ___________________Food ______________________________ Rent ____________________________
Child Support Paid _______________Fuel Oil ____________________________ Rent-To-Own_____________________
Car Gasoline ____________________Gas, Bottled ________________________ School Loan ______________________
Car Insurance____________________Gas, Natural ________________________ Storage __________________________
Car Payment ____________________Health Insurance _____________________ Telephone________________________
Condo Fee ______________________Laundry____________________________ Other ___________________________
Child Care ______________________Loan ______________________________ Other ___________________________
Credit Card _____________________Lot Rent ___________________________ Other ___________________________
List unplanned, emergency or irregular periodic expenses during the past 30 days:
Car Inspection ___________________Drivers License______________________ Medical _________________________
Car registration __________________Fines/Court Payments_________________ Sewer/Water______________________
Car repair_______________________Home Repairs _______________________ Tax (Income/Property)______________
Dental _________________________Home/Rent Insurance _________________ Other ___________________________
7. Criminal Information
Have you or any member of your household ever been convicted of a felony which has not been annulled? (yes/no)
If yes,__________________________ Who?_______________________ When? ________________________________
Town/City & State of conviction __________________________Details of conviction: ____________________________
Are you or any member of your household presently on parole or probation? (yes/no)_______________________________
If yes, who? _________________________________ Court or jurisdiction?______________________________________
Name & phone number of parole/probation officer __________________________________________________________
8. Liability for Support Information
Please provide following details:
Your father _____________________________________ Address ____________________________________________
Your mother ____________________________________ Address ____________________________________________
Co-applicant father _______________________________ Address ____________________________________________
Co-applicant mother ______________________________ Address ____________________________________________
Your or co-applicant’s adult children _____________________________________________________________________
9. Certifications and Signatures
I understand that if I receive assistance from the municipality I may be required to participate in the welfare work (“workfare”) program.
(RSA 165:31)
I understand that I may be required to repay any assistance provided, after deduction of the value of workfare hours I have completed, if I
am returned to an income status which enables me to reimburse without financial hardship. (RSA 165:20-b).
I understand that if I am assisted the municipality may place a lien against any real property which I own. (RSA 165:28)
I hereby certify that if I have a lawsuit, worker’s compensation claim, or aid from any other social service agency now pending, I have
listed these in this application. I further agree to notify the Welfare Official immediately upon receipt of any money from or upon the
settlement of such claim. I understand that if I am assisted, the municipality may place a lien against any property settlement or civil
judgment for personal injuries which I receive within six years of receiving municipal assistance. (RSA 165-28a)
I hereby certify that the information I have provided on this application is 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 or Co-applicant Signature Date
_____________________________________________ ________________________
Signature of person completing form Date
(if not applicant)
TOWN OF HUDSON
MEDICAL RELEASE AND REPORT
APPLICANT NAME/SS#: ______________________________ DOB:____________________________________
I hereby request the release by a doctor, hospital or clinic to the Local Welfare Administrator for the Town
of Hudson, or its authorized representative, any information regarding my medical diagnosis, medical
history, treatment plan or hospitalization. A photocopy of this signed release may be used in place of an
original, in effect for six months from date of my signature below:
________________________________________ __________________________
APPLICANT SIGNATURE DATE
TO THE PHYSICIAN OR CLINIC:
The person named above has indicated that he/she is currently unable to work and is in treatment with
you. New Hampshire General Assistance laws require able-bodied welfare applicants to seek and retain
work as a condition of continued assistance, with the goal of minimizing the period of assistance
necessary. The Municipality also may require welfare recipients to work in any capacity that the recipient
is able in exchange for assistance. For these reasons, will you please briefly respond to these questions:
What is the condition(s) for which you are treating this person? _________________________________
What is the nature and extent of this individual’s limitations? ___________________________________
Is this person disabled? No Yes (If yes, please clarify below)
Temporarily Permanently Partially Totally
Date incapacity began: ____________________________ Expected to end: _______________________
When will this individual be capable of returning to work? What type of work would be suitable for this
individual? Please describe any limitations: _________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Medications Prescribed: ________________________________________________________________
________________________________________ ____________________________
Physician Name / Signature Date
Thank you for taking the time to complete this form.
Please contact the Town of Hudson at
(603) 595-6518 if you have any questions.
Town of Hudson
RENTAL VERIFICATION FORM
THIS FORM MUST BE COMPLETED BY THE LANDLORD
Tenant’s Name: ________________________________________ Date: ___________________________
Address: _______________________________________________________________________________
(Number/Street) (Apt. #) (City) (State)
Number of Household Members:______________ List of Household Members: ______________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Occupancy date: _____________ Security Deposit: Amount: $ ____________ Date paid: _____________
Rent amount: $ _______________; paid monthly weekly other ______________
If subsidized rent, please list tenant portion: $_____________# of Bedrooms: ____________
Rent Includes: All utilities No Utilities Hot Water Heat Electric
Type of Heat: Electric Oil Gas Other ______________
Date last rent was paid: _____________ Amount Paid: $ ____________Back rent owed: $_____________
(if back rent is owed, please attach accounting of months and amounts)
For IRS reporting, landlord’s Tax ID or Social Security # must be provided:
Tax ID #: ___________________________OR Social Security #:________________________________
CHECK IS TO BE MADE PAYABLE TO: (PLEASE PRINT)
_______________________________ ____________________________________
Landlord’s Name Telephone / Fax Numbers
______________________________________________________________________________
Landlord Address
______________________________________________
Name of Manager or other Representative
_______________________________________________ __________________________________
Landlord Signature Date
Town of Hudson
EMPLOYMENT VERIFICATION FORM
THIS FORM MUST BE COMPLETED BY THE EMPLOYER
To Employer_____________________________________________________ Date __________________
Address________________________________________________________________________________
Phone _______________________
For the purpose of administration of municipal assistance, the following information is required for:
_________________________________________
[name of employee]
Date of Hire _____________ _____ Date starting/started work ___________Hourly Pay Rate ________
Full/part time __________ Hours per week__________ Paid weekly biweekly other _______
Date of first/most recent paycheck___________________ Net amount_________________
================================================
If________________________________ is no longer employed by your company:
Date of termination/separation_______________ Date/net amount of last paycheck _______________
Reason for termination/separation _________________________________________________________
__________________________________________________________ _____________________
Signature and Title of immediate supervisor or person completing form Date
Town of Hudson
APPLICANT’S AUTHORIZATION TO FURNISH INFORMATION
I/We, _________________________________________, authorize any relative, physician, lawyer,
banker, employer, insurance company, mental health professional, school official or other person or
organization having information concerning my/our circumstances to furnish such information to the
Local Welfare Administrator for the Town of Hudson. I/We also authorize the Internal Revenue
Service, Social Security Administration, any State or County Division of Health and Human
Services, Division of Children Youth and Families, Division of Adult and Elderly, New Hampshire
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 Local Welfare Administration for the Town of Hudson.
___________________________________ _________________________
Applicant Signature Date
___________________________________ _________________________
Spouse or Co-applicant Signature Date
__________________________________________________________________
Signature of person completing form (if not applicant); Relationship to applicant
__________________________ __________
Welfare Official Signature Date
Town of Hudson
AUTHORIZATION FOR THE RELEASE OF INFORMATION – DHHS
I,____________________________________________ , the undersigned, understand that from time to time,
Print Your Name
the local welfare administrator for _______________________________ may require certain information about
Town/City
assistance I am applying for or receiving from the New Hampshire Department of Health and Human Services, Division of
Family Assistance (DFA). When information cannot be provided by me personally, I hereby authorize DFA to release the
following information to the local welfare administrator for the specific purposes outlined below:
Type of Information Purpose for Requesting this Information
Date of DFA application(s), type(s) of assistance
applied for, date of eligibility determination,
expected date of benefit issuance, amount of cash
grant (if applicable) and/or the reason my case closed
or my application was denied
Basic administration of my local welfare assistance case
including verification of information provided by me for
determining eligibility for local welfare assistance
Date my Medicaid case opened and my Medicaid
Identification Number(s)
Processing of Medicaid reimbursements if/when, during
the time my Medicaid application was pending, the local
welfare administrator makes an expenditure on my behalf
for an item covered by Medicaid
Date of any sanction of my cash assistance grant Determining countable household income also called
“deeming”
Reason for any sanction of my cash assistance grant Helping me to remove the sanction
I understand that I have the option to provide any or all of the requested information myself.
I understand that any use of the above information inconsistent with these purposes is forbidden.
I understand that the local welfare administrator may not release information provided under this authorization to any other
person without my written permission.
This authorization shall expire 180 days from the date it is signed.
___________________________________ ________________________
Signature Date
If the signature above is not that of the person to whom the requested information pertains, the relationship of the signer to
that person must be indicated, the signature must be witnessed, and verification that the signer has the authority to represent
the person in these matters with DFA must be provided upon DFA request.
________________________________ _______________________________ _______________________
Relationship to You Witness Date
PLEASE READ AND SIGN
RSA 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 to assist
such person if his weekly income is more than sufficient to provide a reasonable
subsistence compatible with decency and health.
RSA 165:20 Recovery of Expense
– If a town spends any sum for the support, return
to his home, or burial of an assisted person having relations able to support him under
Section 19 of this chapter, such sum may be recovered from the relation so
chargeable.
*I have read RSA 165:19 and RSA 165:20 above and understand that I am liable
to assist now or that The Town of Hudson can bill me and recover assistance
given to:
_________________ _____________
Applicant Signature Date
_________________ _________________
Relative Signature Relative Signature
Date: ____________
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Town of Hudson Application for Assistance (Town of Hudson)

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Completed 23 January 2021

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