Womenaid Request Form

Womenaid Request Form

Thank you for making this request on behalf of a community member in need. Please complete the following form to ensure that we have all the information we need in order to make a timely decision on your request. Thank you!
Validator Information
Your name*
E-mail*
Your organization or connection to the person in need*
The Need
1. The city or town where the person in need lives*
2. Has the person been helped by Womenaid in the past 12 months?*

Yes No
If yes, how much was the amount contributed by Womenaid, when, and for what reason?
3a. The exact amount of money needed*
3b.The exact amount requested*
How Assistance Will Be Used

Below are categories of need. Please select the appropriate one in the drop down menu and also answer the questions marked by asterisks; also provide a narrative explanation so that Womenaid can understand the need for the request. The space will expand to allow for your complete explantation.
HOUSING
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).

*if this is a request for current rent, has the town welfare office been contacted? We have learned that they can assist with current rent. Remember that we may be able to help in another area that is not covered by welfare.
UTILITIES
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).

*If this is a request for a current utility bill, has the town welfare office been contacted? We have learned that they can assist with current utility bills. Remember we may be able to help in another area that is not covered by welfare.
** If this is a request for either current or past due natural gas or electric payment, has the client contacted their local Community Action organization regarding fuel assistance, payment waivers, and/or payment plans or rate reductions? Have they requested and been denied payment waiver or fee reduction from their utility provider?
TRANSPORTATION
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).

*If this is a request for car repair, in your explanation please give the make and model of the car, the source of the estimate for repair, and some verification that the repairs requests will enable the car to be safe and roadworthy. If the estimate is from a National Chain store, we respectfully reserve the right to request another bid for the service.
MEDICAL
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).
CHILDCARE
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).
OTHER LIFE NEEDS NOT LISTED ABOVE
Please give us some background information on the situation at hand (use of client's name is optional unless we specifically request it).

* If this request is for food, has the town welfare office or local food pantries been contacted? This is not mandatory but we have learned that they can assist with this. Remember we may be able to help in another area that is not covered by welfare.
The Resources Contacted for Assistance

Please list all the other resources and avenues of assistance that have been contacted relative to this request. This avoids duplication of services and appropriately places Womenaid of Greater Portsmouth in its correct position of being "the last resort" or "the last piece of the puzzle" in providing assistance.
Resources Contacted*
The Reason

Please tell us why you believe Womenaid is the correct resource to meet this need.
Why Womenaid*
PAYMENT
Vendor to be Paid*
Contact Name*
To ensure payments are applied properly, we need to have an account number, car year/make/model or name to reference in the check memo.

Address of Where to Send Payment*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Vendor Phone Number, if possible
- Area Code Phone Number
Enter the message as it's shown*
Should be Empty:

Womenaid Request Form

Validator Information

The Need

How Assistance Will Be Used

The Resources Contacted for Assistance

The Reason

PAYMENT