Eastern Pequot Tribal NationP.O. Box 208 North Stonington Ct 06359
Application for Emergency Assistance
Date: ____________ Name (print) _________________________________________Address: ______________________________________________________________________________________________________________________________________________________Date of Birth: _____________ Phone # ( ) _____-_______E-MAIL Address: ________________________________________Date funds are needed: _____________ Total $ amount requested: _________ (Applicants are awarded $200 per calendar year)Have you attempted to obtain assistance from your local community services? Yes or No (circle one)Reason for request of funds (please explain) If more explanation is needed, please use back of form.______________________________________________________________________________________________________________________________________________________Please provide the name and address of the company (s) to whom the checks will be mailed. (Example: CL&P, Doctor, Landlord Etc.) ** Please include a copy of current bill**______________________________________________________________________________________________________________________________________________________________________________I certify that my income is $_____________ per year or that I am unemployed or retired.Applicant Signature_______________________________ Date: __________________==============================================================
Office use only:Date application was sent_______________ Date application was received___________ Received by whom________________________Approved____________ Denied______________Approved amount_______________Date_________________ Check number________________Authorized signature _________________________________________
If you are in need of assistance with an application please contact Kathy at 860-389-7018 or Brenda at 860-574-6351 or email [email protected]
