Farmington Welfare Intake

Farmington Welfare Intake

603-755-3100 / welfare@farmington.nh.us
STOP -- IS THIS AN EMERGENCY? IF SO CALL IMMEDIATELY
- Your power was shut off or will be shut off by the end of the week
- You don't have a place to sleep and cannot pay for lodging tonight
- You don't have a place to sleep and shelters are unavailable tonight
- You don't have a place to sleep and cannot stay with family or friends tonight
- You ran out of fuel (winter months)
- Food
- Emergency Medication
Clients are seen by appointment except in the case of a documented bona fide emergency which could result in harm to the applicant.
Name*

First NameLast Name
Address*

Street

Street Address Line 2

Town or CityHow long at this address?

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Appointment
Personal Information*

Date of Birth

Social Security Number

CityState / Province

Postal / Zip Code
Please list ALL other household members with ages:
Income Amount & Source*
What type of assistance are you requesting at this time?*
Have you received prior assistance from this office?*

YesNo
If yes, when?
Any other information you would like to note:
Applicant Signature

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