HOUSING & UTILITIES

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!

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.

Validator Information

Validator Name : *

First

Last

Validator Email : *

Validators organization or connection to the person in need : *

The City or Town Where Person Lives : *

Please click here for links to other Womenaid groups.

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

NO YES

If YES, please note amount and for what purpose? *

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

How many members of the household (ages, etc). *

Transportation or Vehicle Repairs

NOTE: We recommend having more than one repair estimate from local businesses, whenever possible. If possible, please attach a copy of the estimate with this request.

Full Description of Repairs Needed.
(If Estimate is not Attached to this Request) : *

If YES, Please explain reason for denial.
Welfare guidelines indicate that municipal welfare is able to assist with current rent.
Perhaps we can help with another need, in order to free up funds for rent. *

Utilities

Utilities: *

* If this is a request for a current utility bill, has the town welfare office been contacted? *

Yes No

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?

Contacted their local Community Action organization? *

Yes No

Have they requested and been denied payment waiver or fee reduction from their utility provider? *

Yes No

Please give us some background information on the situation at hand: *

The Resources Contacted for Assistance

Please list all resources you have contacted for this need, and the reason for decline (or amount of assistance they are providing, leaving an unmet need.) Womenaid provides the "last piece of the puzzle, to avoid duplication of services, and to be sure the person or family is accessing the maximum amount of assistance for which they are eligible. Examples: Community Action, SHARE, Operation Blessing, Service Link, Town Welfare, Families First.

The Resources Contacted for Assistance *

Payment Details

Vendor To Be Paid: *

PHONE Number for Vendor Contact :
(We hope to pay by credit card or by phone) *

Vendor Contact Name : *

EMAIL for Vendor Contact : *

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

Client NAME :
(Strictly Confidential) *

Client ACCOUNT NUMBER:
(Strictly Confidential) *

Mailing Address for USPS Mailing of a Check: *

Line 1

Line 2

City

State

Zip Code

Country

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Validator Information

Transportation or Vehicle Repairs​

Utilities

The Resources Contacted for Assistance

Payment Details

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

Transportation or Vehicle Repairs