TOWN
OF SEABROOK
APPLICATION FOR LOCAL WELFARE ASSISTANCE
It shall be the right of any
individual regardless of race, age, sex, religious or political affiliation to
make application for local welfare assistance.
All application forms and related material become the property of the
Town of Seabrook and shall be considered confidential. Each application will be reviewed
individually with the applicant or his representative before a determination of
eligibility is made. Should the
applicant be aggrieved by the ultimate determination of eligibility, the
applicant/recipient shall be entitled to a fair hearing within seven (7) days
of request.
Each applicant has the responsibility, at the time of application and continuing thereafter to:
1.
Provide accurate,
complete and current information concerning needs and resources.
2.
Notify the welfare
office of changes in needs, resources or circumstances within 72 hours.
3.
Apply for and utilize
any benefits or resources that will reduce or eliminate the need for local
welfare assistance.
IT IS
UNLAWFUL for any applicant or
recipient to knowingly make a false representation verbally, in writing, or by
omission, as to his circumstances.
Anyone who does so may be subject to criminal prosecution for such
actions.
Upon application for Town
assistance, applicants are required to provide the following:
1.
Complete application in
its entirety. Incomplete application
will result in the delay of a decision on the requested assistance.
2.
Submit verification of
rent, electric, and any other expenses listed.
3.
Applicants will be
required to actively seek assistance from all other government programs or
human service agencies.
4.
Applicants who receive
assistance are required to register with the Department of Employment Security
within seven (7) days of application unless medical reasons prohibit
(documentation from a doctor must be submitted.)
5.
Failure to comply with
the above requirements and/or requests of the welfare agent may result in
automatic denial of assistance.
6.
Any falsification of
information may subject the applicant to criminal prosecution.
The
Town has 72 hours to act on a completed application unless an immediate need
exists that is a threat to the applicant’s health.
All
applicants are entitled to view a copy of the Town of Seabrook Welfare Rules
and Regulations.
All
applicants who are denied assistance are entitled to a fair hearing if the
denial is appealed.
The
Town has the right to file a lien against any real estate owned, or purchased
within six years, by a recipient of local welfare assistance.
TOWN OF SEABROOK
EXAMPLES OF ACCEPTABLE DOCUMENTATION FOR WELFARE
Below are examples of what you must bring in for each
household member.
Proof
of Identity – Driver’s license, passport,
immunization records, school records.
Citizenship/Alien
Status – Certified birth certificate,
naturalization papers, alien card.
Social
Security Number – You must provide or
apply for social security numbers.
Residence/Shelter
Expenses – Current bills, receipts,
and/or canceled checks for all shelter expenses including rent, mortgage,
property taxes, oil, gas, electric, insurance, telephone, cable, water and
sewer. Landlord verification form may
also be required.
Cash
Resources – Documentation on all cash on hand, bank accounts,
stocks, bonds, trust accounts, and
retirement funds. Proof is shown by
providing check registers, passbooks, bank or credit union statements, brokerage
statements, etc. All documents must
show updated balances from the financial institution.
Personal
Property – Title, registration, bill
of sale, and amount owed on all cars, trucks, campers, boats, motorcycles and
snowmobiles.
Life
Insurance – Actual policy must be
provided, including any recent statements.
Real
Estate – All documents relating to
any and all real estate, including personal residence, rental property and
business property. Documents should
include deeds, mortgage, tax bill, insurance policies, purchase & sale
agreements, and rental agreements.
Earnings – Pay stub or a letter from employer stating gross
amounts earned. If self employed, your
income tax statement from last year, profit/loss statement, and documentation
of earnings and expenses for this year.
Child
Support/Alimony/Divorce/Legal Separation
– All court orders relating to your case and a letter from the person making
payments to you including the amount and frequency of payments.
Other
Income – A copy of the check, check
stub, letter of award from the agency providing benefits, or a letter from the
person making payments. Other income
includes Social Security, SSI, VA Benefits, TANF, OAA, APTD, unemployment
compensation, interest & dividends, disability benefits, contributions from
friends/relatives, income from roomers/boarders, and any other income from any
other source.
Employment
Expenses – Pay stubs, receipts,
canceled checks, evidence of mileage, or a statement from your employer
regarding expenses for taxes, insurance, mandatory union dues, retirement plan,
cost of mandatory uniforms or tools, child care, and transportation.
Student
Status/Educational Expenses – A
letter from the school indicating whether the student attends at least half
time. A statement showing any amount
and period covered by scholarships, grants or loans. A statements\ or receipt for tuition, fees, books, supplies,
transportation and personal expenses related to the cost of school attendance.
Proof
of Disability/Medical Expenses –
Medical verification of disability/incapacity.
Evidence of medical expenses including current receipts, canceled
checks, bills from physicians, dentists, hospitals, and pharmacists. Evidence of health insurance premium
including name of company, type of coverage, policy/claim number, and date
coverage became effective.
Have you or members of your household ever received any kind of public assistance? ____________________
When: _________ Type: _____________ Source: ___________________________ Amounts: $________________
Does anyone in your household currently receive food stamps? _____ If yes, how much per month? $_________
Does anyone in your household currently receive WIC or CSFP? _____ If yes, who? ______________________
Is anyone in your household covered by Medicaid, Medicare, or personal medical or dental insurance? _____
If yes, who, what type & what is the cost? ___________________________________________________________
Have you or anyone in your household ever been sanctioned by a public assistance agency? _______________
If yes, who, when & by what agency? ______________________________________________________________
Does anyone in your household have a lawsuit pending which may result in a cash award or settlement? ____
If yes, please give the name & address of the attorney handling the case, and the household member involved.
____________________________________________________________________________________________
If yes, please give details:
________________________________________________________________________
Expenses:
Rent/Mortgage: _________________________________________ Amount $____________ per week / per month
Food (including food stamps used): _________________________ Amount $____________ per week / per month
Electric: _______________________________________________ Amount $____________ per week / per month
Gas / Oil: ______________________________________________ Amount $____________ per week / per month
Automobile Expenses: ____________________________________ Amount $____________ per week / per month
Other Debts (specify): ____________________________________ Amount $____________ per week / per month
Please state below any additional information you feel may impact your individual case.
Signature
Page
I/We hereby certify that I/we have read and understand this application, and that all information provided in this application is true and I/we understand any misrepresentation which affects my eligibility or amount of aid I/we may receive can cancel aid from the Town of Seabrook, and may result in court action for recovery.
____________________________________ ____________________________________
(Applicant) (Date) (Spouse) (Date)
I/We understand that if I/we voluntarily quit
employment without good cause within one year of receiving assistance I/we may
be ineligible for any assistance for up to 90 days from the date of quit.
____________________________________ ____________________________________
(Applicant) (Date) (Spouse) (Date)
I/We
__________________________________, of the Town of Seabrook, County of
Rockingham, hereby authorize and empower the Welfare Agent and the Board of
Selectmen for the Town, or their designated attorney or agent to obtain any
report or other information relating to my property, assets, debts, financial
circumstances, or health; and in consideration of the financial aid which I am
requesting from the Town, I hereby promise and agree to reimburse the Town for
the amount of aid rendered so far as my circumstances will permit, and I
authorize and empower the Board of Selectmen to place a lien upon any property
of mine which I may now have or may hereafter acquire, and this agreement shall
be in addition to any other rights which the Town may have under the laws of
the State of New Hampshire, and shall not waive its rights to proceed in any
other manner.
____________________________________ ____________________________________
(Applicant) (Date) (Spouse) (Date)
County of Rockingham
Personally appeared the above named
_____________________________, this ____ day of ___________, ______, and
acknowledged the foregoing to be true to the best of his/her knowledge and
belief, and to be his/her voluntary act and deed. Before me,
____________________________________
Deirdre
L. Greene, Notary Public
My
commission expires: August 20, 2002