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

Name (first and last)

Address (Street, Apartment # if any)

City, State, Zip

Date of Birth (MM/DD/YYYY)

Does applicant live in subsidized housing?

Yes

Phone

Pronouns

Does applicant

Rent

Own

How long has applicant lived in Sudbury?

What's making this time difficult for applicant financially?

If yes, please include the year(s) that a HOPEfund grant was received. If you are unsure, please write unknown

Please note, there is a limit of 5 lifetime HOPEfund grants per household

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?

Yes

Are there additional household members?

Yes

Second Household Member (include Date of Birth and Relationship to Applicant

Does this person live with the applicant more than 50% of the time?

yes

varies

Is there a third household member?

Yes

Third Household Member (include Date of Birth, Relationship to Applicant

Does this person live with the applicant more than 50% of the time?

yes

varies

Is there a fourth household member?

Yes

Fourth Household Member (include Date of Birth and Relationship to Applicant)

Does this person live with the applicant more than 50% of the time?

yes

varies

Is there a fifth household member?

Yes

Fifth Household Member (include Date of Birth and Relationship to Applicant)

Does this person live with applicant more than 50% of the time?

yes

varies

Is there a sixth household member?

Yes

Sixth Household Member (include Date of Birth and Relationship to Applicant)

Does this person live with applicant more than 50% of the time?

yes

varies

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)

Applicant understands that there is only one grant per household allowed every 12 months; once an application is approved, if someone else from the same household tries to apply, they will be informed that they are ineligible because the grant has already been made to their address.

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.

Bill #1 Company Name

Amount client would like HOPEsudbury to pay

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.

Bill #2 Company Name

Amount client would like HOPEsudbury to pay

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.

Bill #3 Company Name

Amount client would like HOPEsudbury to pay

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.

Bill #4 Company Name

Amount client would like HOPEsudbury to pay

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.

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

Staff Member completing application

Date of Application

SWO 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.

Please hit "submit" only once;

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receive confirmation!

INTERNAL HOPEfund application

Household Information

INTERNAL
HOPEfund application