Please Note: this question does not impact your eligibility for the HOPEfund; it is used by the social work office to offer tailored resources and referrals to meet your needs.
***PLEASE REVIEW THE FOLLOWING***
***INFORMATION WITH CLIENT***
CERTIFICATION AND RELEASE OF INFORMATION
Please be sure you have answered all questions to the best of your ability so that we can process your application quickly and efficiently. After submitting this form, someone from the Sudbury Board of Health Social Work Office will contact you for a phone call to connect you with other needed resources and help submit your application to the HOPEsudbury board. If it is determined that your household is eligible, under the program guidelines, payments will be made on your behalf directly to the vendor of the bill(s) you submitted.
By checking the box below I certify the following:
Certification of application:
I have read, understood, and agree to the HOPEfund Guidelines/FAQ. I understand that my eligibility is dependent on me filling out this application truthfully and to the best of my ability. I promise that the information contained on this application is truthful. If information is found to be untruthful, your household may be ineligible for HOPEsudbury programs. I authorize HOPEsudbury and the Town of Sudbury Social Work Office to verify the information provided.
Release of Information:
I hereby give permission for this application and the information contained within it to be shared with HOPEsudbury Board Members and Town of Sudbury Social Work Office for purposes of approval, payment, and program management. HOPEsudbury shall have no liability related to the release of information.
This application may be executed by electronic signature which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.
Application submitted by SWO