City of Manchester, NH APPLICATION FOR ASSISTANCE DATE_________
Welfare Department
1528 Elm St. Complete Each Section CASEWORKER_____
Phone: (603) 624-6484 Fax: (603) 628-6179
Has any household member ever applied with this office before? Yes___ No___ If yes, When? _______What name?___________________
Name ________________________________________________ Maiden Name_____________________________________________
Address______________________________________________ Cell# (_____) ______________ Tel# (______) _________________
City_________________________ State _____ ZIP___________
Name of Spouse/Cohab/Roommate_________________ Maiden Name_____________________________________________
Cell# (_____) _______________Tel# (______) _________________
LIST EVERYONE WHO LIVES IN THE HOUSEHOLD, BEGIN WITH YOURSELF ON THE FIRST LINE
Marital Social Security Most Recent
Full Name Relationship Status Birthdate Age Number School Attended Grade
____________ __Self___ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
____________ _______ _____ ______ ____ ___________ __________ ____
LIST ALL CHILDREN OF ADULT HOUSEHOLD MEMBERS WHO DO NOT LIVE WITH YOU. INCLUDE ALL CHILDREN OVER 18
Full Name Birthdate Address Employer Name of Guardian if child is under 18
________________________ ______________ _______________________ ____________________ ______________________________
________________________ ______________ _______________________ ____________________ ______________________________
________________________ ______________ _______________________ ____________________ ______________________________
________________________ ______________ _______________________ ____________________ ______________________________
LIST MARITAL HISTORY OF ALL ADULT HOUSEHOLD MEMBERS
Date of Place of Marriage Legal Status Date of Custody of
Your Name Spouse’s Name Marriage City/Town/State (Divorce/Sep/Widow) Div/Sep/Wid Children
________________ ____________________ __________ _______________________ __________ ___________ ____________
________________ ____________________ __________ _______________________ ___________ ___________ ____________
________________ ____________________ __________ _______________________ ___________ ___________ ____________
LIST ADDRESSES FOR ALL ADULT HOUSEHOLD MEMBERS FOR THE LAST TWO YEARS, BEGIN WITH THE PRESENT ADDRESS
Street Address, Room or Apt. # Town / City / State From (Month / Date / Year) To (Month / Date / Year)
___________________________________ ______________________________ ____________________ to _____________________
___________________________________ ______________________________ ____________________ to _____________________
___________________________________ ______________________________ ____________________ to _____________________
___________________________________ ______________________________ ____________________ to _____________________
Has any household member applied for or received assistance from any other city, town, or state welfare office? Yes_____ No_____
If yes, where? ____________________ Who?______________ When? ______________ What type of assistance? _______________________
S:/Application and Forms revised 2017
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LIST YOUR PARENTS AND THE PARENTS OF YOUR SPOUSE, ROOMMATE OR COHAB
Your Name ___________________________________________ Spouse, Roommate or Cohab Name_____________________________
Place of Birth___________________________________________ Place of Birth___________________________________________________
Father ______________________________Tel#_____________ Father __________________________________Tel#_________________
Full Address __________________________ Income __________ Full Address _______________________________Income ______________
Date of Death Date of Death
Employer____________________________ if Deceased_________ Employer _________________________________if Deceased ___________
Mother _____________________________ Tel#_____________ Mother __________________________________Tel#_________________
Full Address __________________________ Income __________ Full Address _______________________________Income ______________
Date of Death Date of Death
Employer_____________________________ if Deceased________ Employer_________________________________ if Deceased ___________
LIST MILITARY SERVICE RECORD FOR ALL HOUSEHOLD MEMBERS - INCLUDE NATIONAL GUARD AND RESERVE DUTY
Name Branch Dates of Service Type of Discharge Type of Benefits Date / Amount of Last Pay
_____________________ _______________ _______________ _________________ ______________ ______________________
LIST CURRENT AND LAST THREE EMPLOYERS FOR ALL HOUSEHOLD MEMBERS. INCLUDE SELF EMPLOYMENT,
SUBCONTRACTING, INTERNET SALES, ETC. INCLUDE EMPLOYMENT OF ALL MINORS
Name Employer Date Last Paid Amount Last Paid Dates of Employment Reason for Leaving
___________________ ________________________ ___________ __________________ __________________ ___________________
___________________ ________________________ ___________ __________________ __________________ ___________________
___________________ ________________________ ___________ __________________ __________________ ___________________
___________________ ________________________ ___________ __________________ __________________ ___________________
___________________ ________________________ ___________ __________________ __________________ ___________________
___________________ ________________________ ___________ __________________ __________________ ___________________
LIST ALL MEDICAL, ILLNESS, ACCIDENT AND/OR INJURY INFORMATION
Is any member of the household under doctor’s care? Yes ___No____ If yes, who? _________________________________________________
Name__________________________ Doctor’s name, address and tel#___________________________________________________________
Diagnosis_________________________________ Medications _________________________________________________________________
Name __________________________ Doctor’s name, address and tel#__________________________________________________________
Diagnosis_________________________________ Medications _________________________________________________________________
Is any member of the household unable to work? Yes____ No____ If yes, who? __________________________________________________
Check Reason: Non Work-Related Accident______ Non Work-Related Illness____ Work-Related Accident______ Work-Related Illness_____
Date of Illness, Accident or Injury _______ If work related, list date Workers Comp. claim filed_______ Date able to return to work_________
If work related, list name and address of employer ____________________________________________________ Tel# __________________
Doctor’s name and address________________________________________________________________________Tel#___________________
Insurance Co. name and address___________________________________________________________________ Tel#___________________
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LIST ALL VEHICLES OF ALL HOUSEHOLD MEMBERS INCLUDING, MOTORCYCLES, RV’S, ATV’S, BOATS, ETC.
State and Registered Date of Purchase Date of Amount of
Year Model Plate # To Purchase Price Last Payment Payment
Own ______ Loan_______
______ _________ __________ _______________ Lease _____ Borrow_____ _____________ ____________ ___________ ____________
Own ______ Loan_______
______ _________ __________ _______________ Lease _____ Borrow_____ _____________ ____________ ___________ ____________
LIST ALL REAL ESTATE PROPERTY OWNED BY ALL HOUSEHOLD MEMBERS – INCLUDE TIMESHARES, etc.
Does any household member own any property(ies)? Yes____ No_____ Property Address(es)_______________________________________________________
Owner’(s) name(s) __________________________________ Purchase date________ Purchase price_______________ Date of last payment(s)_______________
Monthly mortgage(s) payment(s) $_____________ ____________ Are taxes escrowed? Yes _____ No_____ Amount of property tax bill__________________
Multi or Single family?________ Rental income property?______ Amount of monthly rental income__________________ Date last received__________________
Foreclosure pending? _____ Does any household member own any other real estate including timeshares? Yes ____ No ____ Address_____________________
RENTAL INFORMATION Landlord's name________________________ Address ____________________Tel# (______)________________
Rental amount $__________ Due weekly _____ Due every two weeks _____ Due monthly _____ Do you have a lease? Yes_____ No_______
List all names on the lease_____________________________ Is there a co-signer? Yes____ No_____ Name of co-signer __________________
Date rent last paid_______Amount of last payment _______ Rental period from ________ to________ Is the rent subsidized? Yes____ No____
If yes, what type? _______________ Which utilities are included in your rent?_____________________________ How many bedrooms?______
Do you have an Eviction Notice? Yes _____No______ Expiration date______ Have you been to court? Yes ____No_____ Court date__________
Has any person or agency helped you with rent? If yes, who? _______________________________ Amount paid_____________ Date ______
PROPERTY HISTORY Has any household member had any real estate property or vehicles which have been sold, foreclosed, repossessed,
traded, totaled or junked within the last year? Yes __ No___ If yes, who? ___________ List property/vehicle(s) __________________________
Date sold ________Sale price_______________ Date foreclosed ________ Date repossessed, traded, totaled or junked ___________________
FEDERAL INCOME TAX LIST EACH ADULT WHO FILED A 2016______2017______2018_____ IRS TAX RETURN
Name Date Filed Where/How Filed? Date Refund Rec’d Amount Rec’d # Of Dependents Claimed
______________________ _________ _________________ _________________ _____________ ________________________
______________________ _________ _________________ _________________ ____________ ________________________
ASSETS Does any household member, INCLUDING CHILDREN, have any bank or credit union accounts (including business accounts), PayPal
accounts, Direct Express cards, prepaid debit cards, or any other type of financial account(s)? Yes___ No___ List ALL financial accounts.
Name of Bank or Savings Checking Name of Debit
Name Financial Institution Acct. Balance Acct. Balance or Prepaid Card Balance
___________________ ______________________ ______ _______ ______ _______ ______________ _______
___________________ ______________________ ______ _______ ______ _______ ______________ _______
___________________ ______________________ ______ _______ ______ _______ _______________ ______
Has any household member had a bank, credit union acct. or any other financial account closed within the last 6 months? Yes_____ No______
If yes, who?_____________ When?______ What type of acct.?________________ Which bank, etc.?_____________ Location ______________
Does any household member have any of the following assets? Yes___ No___ If yes, list the amount of each asset: 401K________ 403b_____
Trust funds_______ Certificates of Deposit (cds)_________ Mutual funds _________ Retirement acct. _________ Savings Bonds____________
Stocks__________ Deferred Compensation __________ Profit Sharing__________ Annuities ____________ Other ______________________
Has any household member borrowed from, cashed in, or received disbursements from the above accounts within 6 years? Yes_____ No_____
If yes, who? ________________________________ List the date last received ______________ Amount_______________.
Is any household member a participant in, or has been the recipient of, any charitable fundraising or monetary gifts within the
last 6 months? Yes____ No____ If yes, amount last received ______________ Date last received_________ Source_________________
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INSURANCE Does any household member have any insurance policies such as; automobile, homeowner’s, renter’s, life or any other insurance
policies? Yes___ No___ If yes, list the following details for all policies:
Name Name of Insurance Co. Type of Policy Cash Value
_______________________ ________________________ __________ _____________
_______________________ ________________________ __________ _____________
LIST IF ANY HOUSEHOLD MEMBER HAS APPLIED FOR OR IS CURRENTLY RECEIVING INCOME OR BENEFITS FROM THE
FOLLOWING SOURCES. CHECK THE “NONE” BOX, ONLY IF BENEFITS HAVE NOT BEEN APPLIED FOR OR RECEIVED.
Date Date Last
Name Applied Received Amount None
ANB (Aid to the Needy Blind) ___ OAA (Old Age Assistance)___
APTD (Aid to Permanently and Totally Disabled)
Boarders in your household
Cash or any money available or set aside
Disability – Short Term _______ Long Term ________
Food Stamps
Fuel Assistance: Rent _______ Heat ______ Electric _______
Help from friends, relatives, employer, co-workers, etc.
Maternity Benefits
Medicaid
Retirement Pension
Severance Pay
SS______ SSD ______ SSI ______
TANF ______ Relative Payee _______
Unemployment Compensation
Utility Allowance Benefit (from subsidized housing)
Vacation Pay _______ Earned Time_______ Sick Time ______
Veteran’s Pension ______ Veteran’s Disability _______
WIC (Women, Infants & Children)
Worker’s Compensation
Date and amount of last income/financial resource for each
household member
Other
PAST / FUTURE RESOURCES
Is any household member expecting to receive, or has received any Inheritance ____Retroactive disability payment (SSD/SSI/APTD) _________
Insurance claim _______ Workers Comp. settlement _________ or any settlement including lump sum settlements within the last 6 years?
Yes ____ No ___ If yes, who? __________________ Amount received or expected ____________Date received or expected_______________
Has any household member consulted with an attorney or presently working with an attorney for any reason, including a possible lawsuit?
Yes ____No_____ If yes, who? _____________ Explain__________________________ Attorney’s name / Tel#__________________________
GUARDIANSHIP / REPRESENTATIVE PAYEE
Does any household member have a Legal Guardian? Yes ___ No____ and/or Rep. Payee? Yes ___No___ If yes, who? _________________
Name of Legal Guardian or Rep. Payee _____________________________________________________________Tel#____________________
Is any household member a Legal Guardian or Rep. Payee for anyone else? Yes____ No____ If yes, who? _____________________________
What benefits? ____________Name and Tel# of person(s) you are a Legal Guardian or Rep. Payee for _________________________________
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ARE YOU OR ANY OTHER HOUSEHOLD MEMBERS WORKING WITH ANY OTHER AGENCIES? Yes___ No___
Client Name _________________________ Agency __________________________Contact Person ________________________Tel# __________________
Client Name _________________________ Agency __________________________Contact Person ________________________Tel# __________________
LIST ALL HOUSEHOLD MEMBERS ENROLLED IN HIGHER EDUCATION CLASSES
Client Name________________________ School________________________ Full Time______ Part Time_____ Financial Aid Amount___________________
Client Name________________________ School________________________ Full Time______ Part Time_____ Financial Aid Amount___________________
ABSENT PARENT /CO-PARENT INFORMATION FOR ALL CHILDREN WHO LIVE IN YOUR HOUSEHOLD
1. Child's /Children’s name(s) that have the same biological parent__________________________ _________________________ ______________________
Name of absent parent / co-parent ____________________________________ Address ____________________________________Tel #___________________
Does the absent parent / co-parent have visitation or shared custody? Yes _____ No ____ If yes, what are the arrangements? ____________________________
Do you receive support from this parent? Yes____ No____ Are the payments court ordered? Yes______ No_______ Arrearages owed? Yes_____ No _______
Are the child support payments wage garnished? Yes_____ No_____ Date last received ________Amount last received___________ Date next due____________
How is the support paid to you? Cash ______ Check______ Money Order ______ Direct Deposit _______ Child Support Card ________ Other_______________
Recent or upcoming court hearings? Yes_____ No_____ Date of court hearing __________ Reason for hearing ________________________________________
2. Child's /Children’s name(s) that have the same biological parent__________________________ _________________________ ______________________
Name of absent parent / co-parent ____________________________________ Address ____________________________________Tel #___________________
Does the absent parent / co-parent have visitation or shared custody? Yes _____ No ____ If yes, what are the arrangements? ____________________________
Do you receive support from this parent? Yes____ No____ Are the payments court ordered? Yes______ No_______ Arrearages owed? Yes_____ No _______
Are the child support payments wage garnished? Yes_____ No_____ Date last received ________Amount last received___________ Date next due____________
How is the support paid to you? Cash ______ Check______ Money Order ______ Direct Deposit _______ Child Support Card ________ Other_______________
Recent or upcoming court hearings? Yes_____ No_____ Date of court hearing __________ Reason for hearing ________________________________________
3. Child's /Children’s name(s) that have the same biological parent__________________________ _________________________ ______________________
Name of absent parent / co-parent ____________________________________ Address ____________________________________Tel #___________________
Does the absent parent / co-parent have visitation or shared custody? Yes _____ No ____ If yes, what are the arrangements? ____________________________
Do you receive support from this parent? Yes____ No____ Are the payments court ordered? Yes______ No_______ Arrearages owed? Yes_____ No _______
Are the child support payments wage garnished? Yes_____ No_____ Date last received ________Amount last received___________ Date next due____________
How is the support paid to you? Cash ______ Check______ Money Order ______ Direct Deposit _______ Child Support Card ________ Other_______________
Recent or upcoming court hearings? Yes_____ No_____ Date of court hearing __________ Reason for hearing ________________________________________
LIST INFORMATION ON ALL MINOR CHILDREN THAT DO NOT LIVE IN YOUR HOUSEHOLD (Request additional paper if necessary.)
1. Person paying support ______________________Child's/Children’s name(s) that have the same biological parent________________ ___________________
Name, address and Tel # of parent/guardian with whom child resides _____________________________________________Relation to child_________________
Name, address and Tel #of person receiving support payments (if different from the above)_________________________________________________________
Date last paid_______ Amt. last paid________ Cash______ Check______ Money Order _______Wage garnishment ______ Court ordered? Yes _____ No______
2. Person paying support ______________________Child's/Children’s name(s) that have the same biological parent________________ ___________________
Name, address and Tel # of parent/guardian with whom child resides _____________________________________________Relation to child_________________
Name, address and Tel #of person receiving support payments (if different from the above)_________________________________________________________
Date last paid_______ Amt. last paid________ Cash______ Check______ Money Order _______Wage garnishment ______ Court ordered? Yes _____ No______
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Frequency
BASIC EXPENSES Amount Weekly or Monthly Date Last Paid Balance Due Name on Bill
Rent / Mortgage ________________ Wk___ Mo___ ________________ ________________ _____________________
Food ________________ Wk___ Mo___ ________________ _____________________
Diapers ________________ Wk___ Mo___ ________________ _____________________
Gasoline for vehicle(s) ________________ Wk___ Mo___ ________________ _____________________
Household Supplies ________________ Wk___ Mo___ ________________ _____________________
Gas Utility ________________ Wk___ Mo___ ________________ ________________ _____________________
Electric ________________ Wk___ Mo___ ________________ ________________ ______________________
Oil ________________ Wk___ Mo___ ________________ ________________ ______________________
Prescriptions ________________ Wk___ Mo___ ________________ ________________ _____________________
OTHER EXPENSES
Cable/Satellite ________________ Wk___ Mo___ ________________ ________________ ______________________
Car Payments ________________ Wk___ Mo___ ________________ ________________ ______________________
Cell Phone(s) ________________ Wk___ Mo___ ________________ ________________ ______________________
________________ Wk___ Mo___ ________________ ________________ ______________________
Child Care ________________ Wk___ Mo___ ________________ ________________ ______________________
Court Fees, Fines, etc ________________ Wk___ Mo___ ________________ ________________ ______________________
Credit Cards ________________ Wk___ Mo___ ________________ ________________ ______________________
Internet Connection ________________ Wk___ Mo___ ________________ ________________ ______________________
Laundry ________________ Wk___ Mo___ ________________ ________________ ______________________
Personal Loans ________________ Wk___ Mo___ ________________ ________________ ______________________
Pet Expenses ________________ Wk___ Mo___ ________________ ________________ ______________________
Streaming Services ________________ Wk ___ Mo___ ________________ ________________ _____________________
Rent to Own Items ________________ Wk___ Mo___ ________________ ________________ ______________________
Storage Unit ________________ Wk___ Mo___ ________________ ________________ ______________________
Telephone (landline) ________________ Wk___ Mo___ ________________ ________________ ______________________
Tobacco Products ________________ Wk___ Mo___ ________________ ________________ ______________________
Other ________________ Wk___ Mo___ ________________ ________________ ______________________
________________ Wk___ Mo___ ________________ ________________ ______________________
WHAT ASSISTANCE ARE YOU REQUESTING? ____________________________________________________________________________
_____________________________________________________________________________________________________________________
____________________________________________________________________________________________________
WHAT IS THE REASON FOR YOUR REQUEST? ___________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Has any household member ever been convicted of a felony? Yes___ No___ If yes, who? _____________________When?________________
Which state(s)? __________________List all felony convictions for all household members ___________________________________________
____________________________________________________________________________________________________________________
Is any household member presently on parole or probation? Yes___ No___ If yes, who? ____________________________________________
Which city / town and state? ___________________________Name of parole / probation officer______________________________________
Tel#______________ Provide details______________________________________________________________________________________
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_______________________________________________ ____________________________________________
Applicant Name (PRINT) Co-applicant Name (PRINT)
_______________________________________________ ____________________________________________
Spouse Name (PRINT) Co-applicant Name (PRINT)
READ BEFORE SIGNING
My/Our signature(s) below constitutes(s) the granting of my/our authority for the City of Manchester, NH Welfare Department to obtain
verification and/or proof from all sources concerning my/our household’s circumstances. All information supplied by me/us is subject to
investigation and verification.
I/We have the right to request a Fair Hearing based on the receipt of an adverse action issued by the Welfare Official.
I/We, the undersigned, agree to repay the City of Manchester, NH Welfare Department for any assistance granted pursuant to RSA 165.
____________________________ ___________________ __________________________ ___________________
Applicant Signature Date Co-applicant Signature Date
____________________________ ___________________ __________________________ ___________________
Spouse Signature Date Co-applicant Signature Date
APPLICANT’S AUTHORIZATION TO FURNISH INFORMATION
I/We authorize any relative, physician, landlord/rental agent, lawyer, banking/lending/financial institution, school department, check cashing
service, employer, former employer, rental/leasing company, utility, insurance company, health care provider, day care provider, mental health
professional/facility, pharmacy, hospital, emergency care facility, ambulance service, funeral home/crematorium, rent-to-own business, police,
sheriff, State Police, fire department, emergency medical technician, Red Cross, Salvation Army, food pantry, Internal Revenue Service, tax
preparer, accountant, Department of Homeland Security, Social Security Administration, any state or county division of Health and Human
Services, Division of Children Youth and Families, Division of Adult and Elderly, NH Legal Assistance, any town, city, county, state or federal
department, shelter, domestic violence or crisis organization, religious/charitable organization, Department of Employment Security, Veteran’s
Administration, Southern New Hampshire Services, or any other person, company, organization or agency to release all information concerning
my/our circumstances to the City of Manchester, NH Welfare Department.
____________________________ ___________________ __________________________ ___________________
Applicant Signature Date Co-applicant Signature Date
____________________________ ___________________ __________________________ ___________________
Spouse Signature Date Co-applicant Signature Date
APPLICANT’S AUTHORIZATION TO RELEASE INFORMATION
I/We authorize the City of Manchester, NH Welfare Department to release information concerning my/our circumstances to any relative,
physician, landlord/rental agent, lawyer, banking/lending/financial institution, school department, check cashing service, employer, former
employer, rental/leasing company, utility, insurance company, health care provider, day care provider, mental health professional/facility,
pharmacy, hospital, emergency care facility, ambulance service, funeral home/crematorium, rent-to-own business, police, sheriff, State Police,
fire department, emergency medical technician, Red Cross, Salvation Army, food pantry, Internal Revenue Service, tax preparer, accountant,
Department of Homeland Security, Social Security Administration, any state or county division of Health and Human Services, Division of
Children Youth and Families, Division of Adult and Elderly, NH Legal Assistance, any town, city, county, state or federal department, shelter,
domestic violence or crisis organization, religious/charitable organization, Department of Employment Security, Veteran’s Administration,
Southern New Hampshire Services, or any other person, company, organization or agency.
____________________________ ___________________ __________________________ ___________________
Applicant Signature Date Co-applicant Signature Date
____________________________ ___________________ __________________________ ___________________
Spouse Signature Date Co-applicant Signature Date
If you need a disability-related accommodation, notify front desk.
TTY access through Relay NH at 711
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EACH ADULT HOUSEHOLD MUST INITIAL EACH STATEMENT BELOW SHOWING THAT YOU HAVE READ AND
UNDERSTAND THE STATEMENT. PLEASE DO NOT HESITATE TO ASK QUESTIONS.
I understand that if our household receives assistance, then our household members will be required to repay any assistance
provided, if we are returned to an income status which enables us to reimburse the City without financial hardship.
(RSA 165:20-b) ____ ____ ____ ____ (initials)
I understand that if our household receives assistance from the City, adult household members over 18 years of age may be
required to participate in the work program to repay assistance.
(RSA 165:31) ____ ____ ____ ____ (initials)
I understand that if our household receives assistance, the City may place a lien against any real estate property in which any
household member owns. (RSA 165:28) ____ ____ ____ ____ (initials)
I understand that if assisted, the City may place a lien against any property settlement, civil judgment for personal injuries, or
property passing under the terms of a will, or by intestate succession.
(RSA 165:28-a) ____ ____ ____ ____ (initials)
I understand that the City reserves the right to contact and pursue assistance and reimbursement from legally liable relatives.
(RSA 165:19) ____ ____ ____ ____ (initials)
I understand that any changes in my circumstances must be reported to the Welfare Official within 3 working days.
____ ____ ____ ____ (initials)
I understand that misrepresentation or omission of information may result in suspension of assistance. I understand that the
information and documentation I provide is subject to verification.
____ ____ ____ ____ (initials)
I understand that my case will be held open for 6 months from the date of last contact with this office. I understand that should I
return to this office while my case is still open that I must demonstrate compliance with all prior Notices of Decision. This includes
but is not limited to; providing proof of all income and financial resources received and receipts to verify that all monies have
been used only as required on prior Notices of Decision. I further understand that my failure to comply with the requirements of
this office will likely result in reduction, suspension, or ineligibility of assistance.
____ ____ ____ ____ (initials)
VOLUNTARY QUIT LAW
Pursuant to the provisions of RSA 165:1-d voluntary termination of employment without good cause could lead to disqualification
from receiving general assistance in the future.
DO NOT SIGN THE STATEMENT BELOW UNTIL AFTER THE END OF THE INTERVIEW.
I hereby certify that all of the information I have provided both in writing and verbally to Manchester City Welfare is complete and
true. I hereby certify that all notes and/or alterations written on my application by the caseworker(s) during the intake process
accurately reflect my responses to questions and any additional information I provided. I understand that if I knowingly give false
or misleading information or withhold or omit information related to my receipt of assistance, now or in the future, I may be
determined ineligible for assistance and I may be prosecuted for a crime (i.e. RSA 641:3 – Unsworn Falsification and/or RSA
637:4 – Theft by Deception).
Applicant Signature: __________________________________ Date: _________________________________
Spouse Signature: ___________________________________ Date: _________________________________
Co-Applicant Signature: _______________________________ Date: _________________________________
Co-Applicant Signature: _______________________________ Date: _________________________________
S:/Application For Assistance Master Revised – 5-2017
