GOOD SMARITAN APPLICATION

 Weedsport Good Samaritan Fund Application

 

The purpose of the Samaritan Fund is to provide funding and/or assistance in finding available resources for families and individuals in the Weedsport Central School District with verifiable emergency needs when other services or funds are unavailable.  In the spirit of the Good Samaritan, we will may assist those in need who are not residents of WCSD however our priority will be serving those who are residents of WCSD. 

 

The Weedsport Good Samaritan Fund is the last resort.  Eligibility for assistance from other funds and the family’s own resources are considered.

 

 Date: __________________

 

 

 

Applicant’s name: (Please print)________________________________________________________________      

 

Birth date: (Month/Year) _________                                    Phone # _____________________________________

 

Referred by: ____________________________________                    (phone #) __________________________

 

Applicant’s address: _________________________________________________________________________

 

City: ____________________________________ Zip: ________________________ 

 

How long have you lived at this address? (Years/months) ___________________________________________

 

Other adults in the household: (Names and ages) _________________________________________________

 

Number of children (names and ages) __________________________________________________________

 

_________________________________________________________________________________________

 

  

Assistance requested: ________________________________________________          $ _________________

A list of items may be included if appropriate. 

 

 Circumstances leading to current crisis:

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

 

(Use back of paper or additional sheet if more room needed.)

 

Monthly income: ___________________

 

Sources of income: Employment: (For employment income use net amount.) Self $_______ Spouse’s $_________

 

SSI $______ Child support $_______ Other: __________________________________

 

Monthly expenses:                                                                                            Total Expenses $___________

 

Mortgage $______        rent $_____        Lot rent $_____        Food $_____        Utilities $_____

 

Homeowner’s insurance $_____        Car payment $_____        Car insurance $ _____

 

Medical expenses $_______        Transportation expenses $____        Child care $_____

 

Cable $_____        Diapers $_____        Telephone $_____        Laundry $_____         Other $_____

 

 

Has the applicant been assisted by the Weedsport Good Samaritan Fund within the last 12 months? _____

 

If yes, for what purpose: ______________________________________________________________________

 

**What other resources have been contacted for help? ________________________________________________

 

If necessary, do we have your permission to contact any other agencies that we may feel will be helpful in our evaluating your application?      (yes/no)      circle one

 

Signature ___________________________________________________________________

 

Please also print your full name ______________________________________________

 

Criteria:

 

-The applicant is a resident of the WeedsportCentralSchool District. Emergency exception – residents of Port Byron, Cato and/or members of participating churches/organizations.

 

-The need has been created by an unforeseen event that results in an emergency or assists in becoming self-sufficient.

 

-The assistance will solve a problem which is not expected to reoccur in the near future.

 

**Payments of approved applications are made to the vendors. Cash grants are not made to the applicant.

 

 

 

Requests to the Weedsport Good Samaritan Fund are accepted by application only. Completed application should be submitted to:

 

Weedsport Good Samaritan Fund                                           OR: Church or Lions Club Weedsport Good

c/o C. Rooker                                                                              

P. O. Box 714                                                                               Samaritan Fund representative

Weedsport, NY13166



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