INTERNAL
HOPEfund application

Name (first and last)

Address (Street, Apartment # if any, City, State, Zip)

Date of Birth (MM/DD/YYYY)

Pronouns

Phone

How long has applicant lived in Sudbury?

What's making this time difficult for applicant financially?

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.

Household Information

Is applicant the sole household income earner?

Yes

Are there additional household members?

Yes

Second Household Member (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable)

Is there a third household member?

Yes

Third Household Member (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable

Is there a fourth household member?

Yes

Fourth Household Member (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable)

Is there a fifth household member?

Yes

Fifth Household Member (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable)

Is there a sixth household member?

Yes

Sixth Household Member (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable)

Are there more than six household members?

Yes

List Additional Household Members (include Date of Birth, Relationship to Applicant and Percent of Custody (if applicable)

Client acknowledges that they understand that there is only one grant per household allowed annually; if someone else from the same household tries to apply, they will be ineligible because a grant has already been made to this address

BILL INFORMATION

Please provide information about the bills you need assistance with below. In addition to the information requested, we will need a copy of the bill, which should include the following information: name of company, name of applicant, account number (if applicable), and payment address

Bill #1 Company Name

Amount client would like HOPEsudbury to pay

Bill #1

Upload File

Upload a copy of bill #1 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes name of company, name of applicant, account number (if applicable), and payment address.

Bill #2 Company Name

Amount client would like HOPEsudbury to pay

Bill #2

Upload File

Upload a copy of bill #2 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes
name of company, name of applicant, account number (if applicable), and payment address

Bill #3 Company Name

Amount client would like HOPEsudbury to pay

Bill #3

Upload File

Upload a copy of bill #3 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes
name of company, name of applicant, account number (if appicable), and payment address

Bill #4 Company Name

Amount client would like HOPEsudbury to pay

Bill #4

Upload File

Upload a copy of bill #4 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes
name of company, name of applicant, account number (if applicable), and payment address. If you have more than 4 bills to submit with this application, please email: socialworker@sudbury.ma.us.

***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.

By checking this box on behalf of the applicant, applicant agrees to the terms & conditions

Staff Member completing application

Date of Application

Additional notes/details

As the person filling this application out on behalf of applicant, you attest that (a) you have permission from applicant to complete and sign on their behalf, and (b) to your knowledge, the information on application is truthful.

Application submitted by SWO

INTERNAL HOPEfund application

Household Information

Upload a copy of bill #1 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes name of company, name of applicant, account number (if applicable), and payment address.

Upload a copy of bill #2 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes name of company, name of applicant, account number (if applicable), and payment address

Upload a copy of bill #3 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes name of company, name of applicant, account number (if appicable), and payment address

INTERNAL
HOPEfund application

Upload a copy of bill #2 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes
name of company, name of applicant, account number (if applicable), and payment address

Upload a copy of bill #3 here or email a copy to the Sudbury social worker: socialworker@sudbury.ma.us. Please make sure bill includes
name of company, name of applicant, account number (if appicable), and payment address