SPENCER CARES APPLICATION

This application form must be filled out correctly, and all relevant questions must be answered. All information on this application will be kept in strict confidence.

QUALIFICATION GUIDELINES

1) Families must be within 150% of poverty level income.

2020 150% Annual Poverty Level Income
1	2	3	4	5	6	7	8
$19,140	$25,860	$32,580	$39,300	$46,020	$52,740	$59,460	$66

For families/households with more than 8 persons, add $4,480 for each additional person.

2) Number of allowable vehicles (value shall not excees $18,000 per vehicle

Family Size	Number of Allowed Vehicles
1 members	No more than 1 vehicle
2 members	No more than 2 vehicles
3 members	No more than 2 vehicles, unless 3 members working
4-7 members	No more than 2 vehicles, unless 3 members working

3) Maximum Allowed in Checking/Savings/Investment Accounts:

1	2	3	4	5	6	7
$5,000	$5,500	$6,000	$6,500	$7,000	$7,500	$8,000

4) Maximum amount of funding per request is $750.

Phone Number

Actual Cost of Project (Please Attach 2 Contractor Quotes before submitting)

Amount Requested (Maximum Amount $750)

What is your annual income including wages, social security payments, interest income, welfare support, investments, rental property income, farm income, etc.?

Do you have excessive medical expense?

Yes

Please list below your approximate net out of pocket expenses for the year. This will be the cost you paid after Insurance, Title XIX, or any other supplement has paid.

Annual Insurance Costs

Annual Prescription Costs

Other Medical Costs

How many vehicles are in the household?

Value of Vehicle #1

Value of Vehicle #2

Value of Vehicle #3

What are the current balances held in your bank accounts? (Bank accounts are defined as checking, savings, money market, CD's, and other investments)

Have you applied for assistance elsewhere?

Yes

Where else have you applied?

Why are you applying for Spencer Cares funding?

I certify that the information provided on this applicatin is true and compelte to the best of my knowledge and I authorize the SPENCER CARES COMMITTEE to check for verification of this information as needed.

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First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Please upload copies of at least 2 Contractor quotes for your project. If you are unable to upload your documents a this time, please be aware that your application will not be processed until you bring your quotes to City Hall.

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City of Spencer

SPENCER CARES APPLICATION

APPLICANT INFORMATION