New England Farm Workers' Council Fuel Assistance Program printable pdf download

NEW ENGLAND FARM WORKERS’ COUNCIL

FUEL ASSISTANCE PROGRAM

1666 Main Street

Springfield, Massachusetts 01103

(413) 272-2209

APPLICATION NUMBER: _____________________

NAME: _______________________________________

Income for the weeks ending: _____/_____, _____/_____, _____/_____, _____/_____

ONE OF THE ITEMS BELOW MUST BE CHECKED AND THE INSTRUCTIONS FOR THAT ITEM

FOLLOWED.

_____ WAGES: Submit the FOUR (4) pay stubs corresponding to the week ending dates above

_____ UNEMPLOYMENT BENEFITS: Submit the FOUR (4) check stubs corresponding with the week

ending dates above or contact the DET office at 1-877-626-6800 for a print out of your claim record.

_____ EAEDC/TANF/WELFARE: Submit current benefit letter (call 1-800-632-8095 to obtain)

_____ WORKERS’ COMPENSATION/SHORT & LONG TERM DISABILITY: Submit FOUR (4)

check stubs showing the gross benefits received for the week ending dates above. Must show

gross amount, date of loss and frequency of payments.

_____ SOCIAL SECURITY/SSDI/VETERAN’S BENEFITS: Submit copy of current check, copy of bank

statement if direct deposit or call 1-800-772-1213 for a benefit letter.

_____ SSI: Call 800-772-1213 to get a copy of your federal benefit information. You must then call 877-863-1128

for verification of SSP, the state portion of SSI.

_____ PENSION BENEFITS: Submit a copy of the current stub, letter from source indicating gross

benefit amount or copy of prior year’s 1099.

_____ OTHER: If you received income other than above listed items please contact office at (413) 272-2209

for instructions.

_____

NO INCOME: If the above-mentioned person had no income for the weeks indicated then they

MUST COMPLETE FOLLOWING SECTION (be sure to complete following section in its entirety including

the dates) AND COMPLETE THE REVERSE SIDE OF THIS FORM.

**I certify that I received no income during the time period indicated below. I authorize NEFWC to examine

my tax returns in order to verify my income. I understand that in the case of any misstatement of no income,

I may be required to repay the full value of any assistance received and may be subject to criminal

prosecution.

I, _________________________________________ had no income from _____/_____/_____ to

_____/_____/_____. (DATES MUST BE FILLED IN)

________________________________________

____________________ ____/____/____

Signature

Social Security #

Date

REMINDER

ANY INDIVIDUAL CLAIMING “NO INCOME” MUST COMPLETE ABOVE SECTION (INCLUDING

DATES) AND COMPLETE THE REVERSE SIDE OF THIS FORM.

New England Farm Workers' Council Fuel Assistance Program