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
