| REQUEST FORM |

Womenaid Request Form

Dear Validators,
In the coming weeks Womenaid will launch a brand-new website that will also include an updated request form. Our hope is that the new website and form will make requesting assistance easier. Thank you!

Womenaid accepts requests for financial assistance from community validators on behalf of individuals and households in need who have nowhere else to turn. These individuals and households must live in our catchment area, which includes, Portsmouth, New Castle, Newington, Rye, Greenland, NH, and Kittery, ME. NOTE: We consider requests on behalf of unsheltered individuals who receive services in our catchment area. ( Here is a link to Womenaid groups serving other towns. )

Womenaid seeks to be the last piece of the financial puzzle to ensure that the whole need is being met.
Our maximum annual funding per HOUSEHOLD is $1000.

Before submitting a request please be sure you have the following information:

Client's town of residence.
Whether this person/family has been helped by Womenaid of Greater Portsmouth in the past 12 months.
The full amount you are requesting.
Other resources or avenues of financial support that have been contacted.
Detailed information about the request, the person's overall financial situation, and why our help is needed.
The vendor's contact information.
For car repairs, include verification that the car will be safe, registered, and roadworthy after repairs have been completed.
For rent, food, and utility payments, please contact town welfare or the local Community Action center prior to submitting a request.

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!