Application

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To apply for assistance from the Wayland Community Fund, please complete the online application below or print and mail the application to

Wayland Community Fund Inc.

297 Boston Post Rd. #196

Wayland, MA 01778

Please call 781-531-5435 if you have any questions and or would like help filling out the application.

This application will be used to determine your financial eligibility for assistance from the Wayland Community Fund. In order to receive assistance the applicant must prove residency in Wayland for the duration of one year and also demonstrate that he/she does not have sufficient financial resources from any other source to pay for the necessities of life.

This committee has the right to request verification to substantiate the information that you provide on this application. When we have complete information, you will receive notice of our decision as soon as possible.

If you have any questions and or would like help filling out the application, please call the Wayland Community Fund Committee at 781-531-5435.

All applications should be mailed to:

Wayland Community Fund Inc.,

297 Boston Post Rd. #196 ,

Wayland, MA 01778

Date(s) of Prior Request(s)

Last Name First Name Middle Name or Initial

Street Address Home

Telephone

(###)

###

####

Email Address

How long have you lived in Wayland?

Date of Birth

YYYY

How did you hear about the Wayland Community Fund?

Please provide the full name and information about all household members: Name, DOB, Relationship to Applicant, Occupation

Please explain briefly why you are seeking financial assistance at this time.

If you are requesting that the Wayland Community Fund pay any bills on your behalf, please list the name, address, and phone number of any person or company to whom these payment would be sent.

* If any

Also please list the exact amount that you owe, and attach a copy of the bill. Assets: Please list all bank accounts, certificates of deposit, credit union accounts, money market accounts, stocks, bonds, or mutual funds for you as well as your spouse. Household Member Type of Asset Current Value

* If any

Income: List all types and sources of income for each household member. Include salary, wages, business income, dividend or investment income, pensions, unemployment compensation, disability compensation, social security/SSI/SSDI, AFDC/welfare/transitional assistance, alimony and child support, veteran’s benefits, etc. Household Member Type or Source of Income Amount per month

Total Monthly Income:

Do you receive any other government or private assistance, such as Food Stamps, Fuel Assistance, subsidized housing, access to a food pantry, etc.?

Estimated Monthly Expenses/Type of Obligation/Amount Paid Monthly/Amount Owed for Auto Loan

Food:

Owed monthly

Rent:

Owed monthly

Mortgage:

Owed monthly

Car Insurance:

Owed monthly

Gasoline/Vehicle Maintenance:

Owed mothly

Homeowners Insurance:

Child Care:

Child Support/Alimony:

Clothing:

Credit Cards:

Education:

Home Repair/Maintenance:

Legal Fees:

Medical/Dental Expenses:

Prescriptions/Medical Supplies:

Health Insurance:

Taxes (specify):

Cable:

Internet:

Telephone:

Telephone/Cable TV/Internet Package:

Gas:

Oil:

Electricity:

Water:

Other (specify):

Total monthly family expenses:

Total current amount due/overdue:

I certify that the information provided is complete and accurate to the best of my knowledge. I authorize the Wayland Community Fund to make inquiries to verify the information I have provided on this application.