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 ______________________________________________




-The applicant is a resident of the Weedsport Central School District. Emergency exception – residents of Weedsport, resident of the school district of Port Byron or 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's Weedsport Good

Rooker                                                                                       Samaritan Fund representative

P. O. Box 714                                                                              

Weedsport, NY13166

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