• City of Nashua Welfare Department

    City of Nashua Welfare Department

  • Division of Public Health & Community Services 18 Mulberry Street, Nashua, N.H. 03060

  • PH: (603) 589-4555 FAX: (603) 594-3643

  • THIS APPLICATION IS A LEGAL DOCUMENT. Please read carefully before

    completing this application for assistance. Once submitted to the department for consideration, the application and related material become the property of the City of Nashua and shall be considered confidential.

    It shall be the right of any individual regardless of race, age, gender, sexual orientation, religious or political affiliation to apply for local welfare assistance.

    Each application will be reviewed with the applicant in order to make a determination regarding the applicant’s eligibility for assistance. If the applicant does not agree with the decision of the Welfare Official regarding the determination of eligibility based on the current Welfare Guidelines of the City of Nashua, the applicant may request a Fair Hearing within five (5) days of the date of such written decision.

    YOU, THE APPLICANT, ARE RESPONSIBLE AT EACH APPOINTMENT FOR PROVIDING FULL AND ACCURATE INFORMATION REGARDING YOUR HOUSEHOLD INCOME AND EXPENSES, HOUSEHOLD MEMBERS, CURRENT ADDRESS, DETAILS OF YOUR CURRENT SITUATION AND ANY CHANGES IN REGARDS TO THIS INFORMATION.

    All questions must be answered fully. Failure to complete any part of this application may delay processing the request for assistance. Blank spaces will be considered an omission of information. Applicants must comply with any requests for information by the Welfare Official necessary for determination and investigation of applicant’s eligibility for assistance. Failure to comply with requests may result in withdrawal of the application for assistance, denial of assistance requested, or suspension pursuant to RSA 165:1-b.

    *If a question on this form is unclear to you, discuss it with the welfare official.

  • APPLICATION FOR ASSISTANCE

  • Date of Application*
     / /
  • Date of Birth*
     / /
  • Marital Status*
  • Rent or Own (select one)*
  • Date of Birth
     - -
  • Date of Birth
     - -
  • Date of Birth
     - -
  • Date of Birth
     - -
  • Date of Birth
     - -
  • Frequency of rent payment:*
  • Date last paid*
     / /
  • Date due
     / /
  • Do you have a current (choose all that apply):*
  • Do you have a housing subsidy?*
  • Utilities Included in Rent (check all that apply):
  • Date last paid
     / /
  • 3 Applicant work history: Are you currently employed?*
  • Date you started work
     / /
  • Date of most recent paycheck
     / /
  • Date last worked
     / /
  • Date of last paycheck
     - -
  • Are you able to work now?*
  • Are you a US Veteran (have you ever served in the military)?*
  • Discharge Type:

  • 4. Provide information regarding accounts and current balances held by you and all household members (include "Chime" or "Cash App" balances):

    Checking/Savings Acct. # Balance

  • 5. Household Income/Benefits (List actual or estimated regular monthly income/benefits):

  • Date last received*
     - -
  • Date last received*
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -
  • Date last received
     - -

  • 6. Household Expenses (List actual or estimated regular monthly expenses):

  • 8. Liability for Support Information: You must provide information on living relations in the form of mother/father/step-mother/step-father, who may be considered liable to assist in accordance with RSA 165:19.  

  • 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 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)

    I understand that my husband/wife, parents/step-parents or grown children may be called upon to assist me if they can do so without financial hardship to themselves. (RSA 165:19)

    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) and/or Theft by Deception. (RSA 637)

  • Print Name Applicant Signature Date

  • Print Name Co-Applicant Signature Date

  • City of Nashua

  • Welfare Department Division of Public Health & Community Services 18 Mulberry Street, Nashua, N.H. 03060

  • PH: (603) 589-4555 FAX: (603) 594-3643

  • 10. Authorization to Release or Exchange Information:

    I/ We authorize any relative, physician, attorney, banker, employer, insurance company, landlord/shelter staff or any other person(s) or organization(s) having information concerning my circumstances to furnish such information to the City of Nashua Welfare Official. The Social Security Administration, the Division of Health & Human Services and the Department of Employment Security may release information in their files to this office. I/ we authorize the City of Nashua Welfare Department to release information as requested to the Division of Health Human Services, Social Security Administration, Department of Employment Security, school personnel, attorney, physician, landlord, other town welfare offices, or any agencies providing supportive services regarding medical, housing/shelter, or financial assistance.

  • Applicant D.O.B. Co-Applicant D.O.B.

  • Applicant Signature Date Co-Applicant Signature Date

    *The above authorization to release or receive information is in effect for as long as the applicant is currently seeking assistance from the City of Nashua Welfare Office or up to six (6) months after assistance has ended.

  • Should be Empty: