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Please note: it is not possible to save this form; if you leave this page while completing the application, any information you have already entered will be lost.

INTERNAL
HOPEfund application
Does applicant live in subsidized housing?
Does applicant
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Please note, there is a limit of 5 lifetime HOPEfund grants per household

Is applicant currently receiving any of the following Non Cash Benefits? (check all that apply)

Please Note: this question does not impact applicant's eligibility for the HOPEfund; it is used by the social work office to offer tailored resources and referrals to meet applicant's needs. If appropriate/relevant, ask applicant if they are interested in additional mental health resources, social supports, HOPE childcare fund, SWAN, Sara Devons Trust, and gift cards if available

Household Information

Is applicant the sole household income earner?
Are there additional household members?
Does this person live with the applicant more than 50% of the time?
Is there a third household member?
Does this person live with the applicant more than 50% of the time?
Is there a fourth household member?
Does this person live with the applicant more than 50% of the time?
Is there a fifth household member?
Does this person live with applicant more than 50% of the time?
Is there a sixth household member?
Does this person live with applicant more than 50% of the time?
Are there more than six household members?

BILL INFORMATION
Please provide information about the bills applicant needs assistance with in the fields below. Please also upload copies of each bill and ensure all images include the following: name of company, name of applicant, account number (if applicable), total amount due, and payment address.  At this time we can only accept JPG or PNG uploads. Alternatively, applicant may email copies of the bills to to: socialworker@sudbury.ma.us. 1-4 bills may be submitted with each application.

Upload File (jpg or png)

Upload a copy of bill #1 here (we can only accept jpg or png files) 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), total amount due, and payment address. If there are more than 4 bills to submit with this application, please email: socialworker@sudbury.ma.us

Upload File (jpg or png)

Upload a copy of bill #2 here (we can only accept jpg or png files) 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), total amount due, and payment address. If there are more than 4 bills to submit with this application, please email: socialworker@sudbury.ma.us

Upload File (jpg or png)

Upload a copy of bill #3 here (we can only accept jpg or png files) 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), total amount due, and payment address. If there are more than 4 bills to submit with this application, please email: socialworker@sudbury.ma.us

Upload File

Upload a copy of bill #4 here (we can only accept jpg or png files) 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), total amount due, and payment address. If there are 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 review your application before submitting it 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. 

Please hit "submit" only once;

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