Aid 4 Amesbury Financial Assistance
If submitting application by mail, please print this form (use the "print form" button at bottom) and mail with accompanying documentation to: The Pettengill House, Inc., 21 Water Street, Suite 4A, Amesbury, MA 01913
Applicant Name
*
First Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone Number
*
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email
*
example@example.com
What do you need help with? (please select one)
*
Utility (electric, gas, oil, etc.) - Please upload vendor bill below*
Groceries & Hygiene Health
Clothing
Medical (prescription, co-pay, etc.) - Please upload vendor bill below*
Childcare Tuition - Please upload vendor bill below*
Rent (please fill out info in next section)
Other
*Please upload vendor bill in applicant's name
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Cancel
of
Comments:
Rent Assistance
Please complete the following section only if applying for rent assistance.
Amount of Monthly Rent
Landlord's Name
Please enter landlord's full name
Landlord's Phone Number
-
Area Code
Phone Number
I AUTHORIZE THE PETTENGILL HOUSE INC. TO CONTACT MY LANDLORD TO OBTAIN VERBAL AND WRITTEN INFORMATION AND DOCUMENTATION VERIFYING ALL INFORMATION PERTAINING TO MY RENTAL STATUS. FAILURE TO PROVIDE THIS INFORMATION AND DESIGNATED RELEASE AUTHORIZATION WILL RESULT IN APPLICATION BEING INCOMPLETE AND NULL AND VOID.
Do you have a Section 8 Voucher, MRVP?
Yes
No
Do you owe back rent?
Yes
No
If you owe back rent, how much?
Please enter $ amount
Please upload a copy of current lease or documentation from landlord of rental rate and when the rent is due.
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Cancel
of
Household Information
Please list the Head of Household and all other members who live at this residence. Provide the relationship of each member to the Head of Household.
Head of Household (HOH)
*
First Name
Last Name
Head of Household's Date of Birth
*
-
Month
-
Day
Year
Date
Other Household Members
Income Information
Please list total annual income of all household members (include wages, salaries and tips; other income such as alimony, child support; unemployment, Social Security and TAFDC or other benefits).
*
Change in Employment Status:
Terminated from employment
Resigned from employment
Decreased Income:
Unemployed or furloughed
Decreased hours due to COVID-19
COVID-19 quarantine
School/Childcare Closure, parent remaining at home due to remote learning; closure of childcare, childcare programming / activities
Comments:
Certification of Information
*
I/we certify that all information furnished in this application for Aid for Amesbury Financial Assistance is true and complete to the best of my knowledge. Proof of income documentation may be requested.
The Following Documentation is Attached:
A copy of current lease or documentation from landlord of rental rate and when the rent is due.
A vendor bill in applicant's name.
Other
Application Certification
*
I/we understand that the above information is being collected to determine if I/we are eligible to receive emergency financial assistance. I/we certify that all information furnished in this is true and complete to the best of my/our knowledge. I/we authorize The Pettengill House, Inc. to verify all information provided on this application. My/our signature(s) below gives authorization for The Pettengill House, Inc. to release and obtain verbal and written information, documentation, and records with the City of Amesbury. I/we understand funds must be returned to The Pettengill House, Inc. should the applicant misrepresent their income or situation.
Head of Household Signature
*
Date
*
-
Month
-
Day
Year
Date
Spouse/Other Adult Signature
Date
-
Month
-
Day
Year
Date
ALL FINANCIAL REQUESTS ARE CONSIDERED COMPLETED WITH ALL AREAS OF APPLICATION ANSWERED AND REQUIRED DOCUMENTATION SUBMITTED. PLEASE NOTE APPLICATIONS MAY TAKE UP TO 7-10 TO DAYS TO REVIEW AND ADDITIONAL DOCUMENTATION MAY BE REQUIRED.
If submitting application by mail, please print this form and mail with accompanying documentation to: The Pettengill House, Inc., 21 Water Street, Suite 4A, Amesbury, MA 01913.
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