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Information Sheet for Applicants (2)

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Basic Needs Request Form Information Sheet for Applicants

Information on this form and given at the interview will be used to decide if you can receive Basic Needs Request and how much you can receive.

We will contact landlords, utility companies and others to verify information given on this form if it is necessary.

You will get a letter which says your request is granted or denied. If denied, we will say why it was denied.

Below is a list of items you may need to give us. We will let you know what we need.

Earned Income

Unearned Income

  • Pay stubs (most recent four weeks)

  • Social Security Award Letter

  • Employer statement verifying gross wages

  • Pension/Retirement statement

  • Federal income tax return (if self-employed)

  • Unemployment/worker’s compensation benefits

  • Self-employment business records (for three months) if no tax return is available

  • Interest/dividend statements

  • Verification of income ending if in the last 60 days

  • Veteran/military benefits

Identity/Citizenship

Assets

  • Driver’s license or state identification card

  • Bank Statements

  • Birth certificate

  • Certificates of Deposit

  • Passport

  • Retirement Funds (IRS/Keogh/401K)

  • Immigration or naturalization documents

  • Life Insurance Policies

Other Documents Which May be Required

  • Stocks/Bonds/Mutual Funds

  • Copies of medical insurance cards

 

  • Copy of Social Security Card

 

  • Copy of utility bill

 

  • Vehicle registration

 

Basic Needs Request Form Information Sheet for Applicants

Natural disasters such as fire, flood or storms:

  1. List of the assistance requested.
  2. A written estimate of repairs to be made.
  3. Cost of labor and materials is needed.
  4. Proof of the loss.

Repairs/Replacement of septic systems, chimney, plumbing, furnaces and heating stoves:

  1. A written estimate from a reputable repairman of the cost including labor and materials.
  2. Proof that you own the property.
  3. If requesting a heating stove, fire department needs to verify that chimney and hook-ups are safe and existing stove is unsafe.

Evictions (not due to misuse of property):

  1. A copy of the eviction received from your landlord. This must be an official notice that if back rent/mortgage is not paid you will be evicted. This must include landlord’s name, address, and phone number.

Utility Shut Off:

  1. A copy of the shut off notice. This must be an active notice and be in the name of a Basic Needs eligible member of your household and be the result of a broken payment agreement.

Special equipment due to handicap which is not covered by Insurance or Vocational Rehabilitation:

  1. A brief explanation of the disability.
  2. Statement from the doctor regarding the necessity for the equipment.
  3. An estimate of the cost of the equipment.

Notice: If you do not have all the information available, it may delay processing of your Request Form.