| REQUEST FORM |

Womenaid Request Form

Thank you for this request on behalf of a community member in need. Please complete the following form to ensure that we have all the information necessary for a timely review and recommendation.

NOTE: Requests cannot be accepted directly from the individual in need. This form must be submitted by a community validator who will represent the person or family for this transaction. Please click here for more details.

We prioritize assistance to people and families in the following towns:

Portsmouth
New Castle
Newington
Rye
Greenland
Kittery

( Here is a link to Womenaid groups serving other towns. )

Validator Information

* Indicates required field

Validator Name : *

First

Last

Validators organization or connection to the person in need : *

Validator Email : *

Validator’s preferred phone number: *

Client/Person in Need Information

Name of Person in need: (strictly confidential and for file only) *

City/Town where this person lives: *

In-Area support includes: Portsmouth, Greenland, Newington, New Castle, Rye and Kittery.
Out-of-Area support is considered on a case-by-case basis. (Please click here for links to other Womenaid groups)

How many ADULT members of the household? *

How many CHILDREN are members of the household? *

Please describe the situation and reason for this request. Be specific as possible. *

Exact amount being requested? *

Will this bring the issue to a zero balance? *

YES NO

If no, please explain how that balance will be paid & by whom? *

Has this person received funding from Womenaid in the past 12 months? *

NO YES

If Yes, how much did Womenaid contribute? *

The Resources Contacted for Assistance

Please list all other resources and avenues of assistance that have been contacted related to this request. Such as: SHARE, Welfare, Community Action Partnership.

The Resources Contacted for Assistance: *

If another resource declined to provide assistance, please provide the reason why. *

If this request is related to car repairs, please attach the work estimate here, and have the mechanic confirm the vehicle will be road worthy once the repairs are completed.

Upload File *

Max file size: 20MB

Payment Details

Vendor To Be Paid: *

Contact Name : *

Contact phone number at Vendor: *

To ensure payments are applied correctly, it's essential that we have:

Client name: (Strictly confidential) *

First

Last

Client ACCOUNT NUMBER: (Strictly Confidential) *

Where to Send Payment (if made by check): *

Line 1

Line 2

City

State

Zip Code

Country

Submit Form

Womenaid Request Form

Womenaid Request Form

Validator Information

Client/Person in Need Information

The Resources Contacted for Assistance

Payment Details

Get in touch. We'd love to hear from you!