Your Information

Name*
Date of Birth*
UPLOAD: Identity Documentation*
(File uploads have been disabled for this form.)
Upload one of the following documents:Driver’s License, Passport, State Identification Card, SNAP Card, Senior MBTA Charlie Card, US Military Identification Card

Current Address
Supporting Proof of Address
(File uploads have been disabled for this form.)
Please upload one of the following documents: Copy of utility bill with service address; Most recent Massachusetts Income Tax Form; Copy of 1040 or 1099; Copy of pay stub or benefit check; Copy of official government notification or benefit letter; Copy of current lease or section 8 agreement; Receipt from landlord for rent received; Copy of deed or mortgage statement; current Government-issued photo identification with current address; or Statement from landlord affirming residency

Need

Areas in which assistance is requested*

Rental Information

What is the address for which you are looking for assistance:*
Copy of Lease*
(File uploads have been disabled for this form.)
Has your ability to pay rent been negatively affected because of the COVID-19 pandemic and the resulting economic crisis?

Landlord Information

Collecting landlord contact is a critical step in the application process, without this information the application will be considered incomplete and will not move forward.

Landlord's Name*
Landlord’s Address*

By signing below I understand that Action for Boston Community Development, Inc. (ABCD) will maintain the confidentiality of personal and financial information I provide, except that ABCD may share information with individuals within ABCD or acting for ABCD as necessary to provide services to me, to keep me updated about ABCD programs, services and initiatives and to administer its programs and ABCD may disclose information upon request of or as required by ABCD’s funding sources and/or for purposes of internal or external audits, monitoring, investigations or evaluations, and as authorized or required by law, legal process, or court order. For any other purpose, ABCD will only disclose information with my written consent.

I hereby certify that the information presented in this declaration is true and accurate to the best of my knowledge. I understand that providing false representation in this declaration may constitute an act of fraud. Further, misleading or incomplete information may result in denial or termination of services.

By signing below, I am confirming that I understand the following:
By signing below, I am confirming that I understand the following:
  Yes
I understand that the funds are only short term assistance to assist with my housing crisis
I understand that there is a cap on the total amount of rental assistance each household may receive in a 12-month period.
I understand that the ABCD Housing and Homelessness Prevention Department, will only pay the agreed amount once you have met your obligations
I understand that failure to follow guidance could result in disqualification from any future funding assistance
I understand that my landlord/property manager and/or housing authority and/or mortgage company must be willing to participate and accept funds from a third party and provide all requested documentation to ABCD
I understand that some funding resources may require a residency priority or must have resided in a community within the last year
I understand that there are income eligibility criteria associated with this program that I must meet to be eligible for funds
I understand that I must live in the rental unit and pay my monthly rent payment as stated in the rental agreement on time once the requested rental assistance is paid
I provide consent for the exchange of information between ABCD and other partnering agencies, including updates from your landlord/property manager and/or housing authority and/or mortgage company
I understand that I must provide all requested documentation in a timely manner to determine eligibility for the funds
I understand that I must notify ABCD of any problems with the landlord or rental unit and/or any changes in the rent/mortgage amount
By signing below, I am confirming that I understand the following: *
By signing below, I am confirming that I understand the following:
  Yes
I understand that the funds are only short term assistance to assist with my housing crisis
I understand that the funds will pay move-in costs including first and last month's rent, providing up to $5,000 per household.
I understand that the funds must be connected with renting an apartment/room with a Medford address.
I understand that the funds will only be provided for a minimum one - year lease or rental agreement for the apartment/room
I understand that the ABCD Housing and Homelessness Prevention Department, will only pay the agreed amount once you have met your obligations
I understand that my monthly rent may cost no more than 50% of my household income
I understand that the tenant, landlord, and ABCD must sign an agreement that specifies the purpose of the funds.
I understand the funds will only be paid directly to the landlord.
I understand that I must notify ABCD of any problems with the landlord or rental unit and/or any changes in the rent/mortgage amount
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Demographic Information

Is your English Limited?

Universal Assessment

Do you have a disability?*
What types of health insurance do you have (check all that apply)?*
Have you served in the U.S. Armed Forces?*

Employment Assessment

Food Security Assessment

In the past 12 months, I was worried whether our food would run out before we got money to buy more.*
In the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.*

Child Support Policy

Are you a single parent who has custody of child under the age of 18?

If you are, you may be eligible for help from the Massachusetts Department of Revenue with obtaining child support from the father or mother of your child.

What types of services would the Department of Revenue provide?

Some of the services the Department of Revenue provides to eligible parents include:

  • Locating a parent
  • Arranging for paternity testing
  • Establishing a support order
  • Enforcing a support order

How do I find out more?

We can provide you with a detailed written explanation of the services, eligibility requirements, and other information, including an application to the Department of Revenue.  Ask a member of the ABCD staff for more information or contact the Department of Revenue directly at:

Massachusetts Department of Revenue

(800) 332-2733 (outside Boston)

(617) 660-1234 (within Boston)

http://www.mass.gov/dor/child-support/

*
Are you the custodial parent/guardian of a child/children?*

Non-Cash Benefit

Is anyone in your household receiving any of the following non-cash benefits?*

Education Assessment

Household Composition

List all Household Members, excluding yourself, their date of birth & their relationship to you: 

A household consists of all people, related or otherwise, who:

  • Occupy the same residence; and
  • Share rent; and
  • Share utilities; and 
  • Share food; and/or
  • Dependents and minors who occupy a housing unit with a client are considered part of the household.
Do you have Household members to add?*

Household Members & Income

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source?*

Household Members & Income (2)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (2)*

Household Members & Income (3)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (3)*

Household Members & Income (4)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (4)*

Household Members & Income (5)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (5)*

Household Members & Income (6)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (6)*

Household Members & Income (7)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)
Add Household Member or Income Source? (7)*

Household Members & Income (8)

Name*
UPLOAD: HH Identity Documentation*
(File uploads have been disabled for this form.)
Birthdate
$
$
UPLOAD: HH Income Documentation*
(File uploads have been disabled for this form.)

Financial Assessment

Please include all sources of income from the past 30 days.  Specify the dollar amount received and select how often you receive it.  Upload related documentation.

Applicant Income Source 1

Income Recipient*
UPLOAD: Income Source Document 1
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 1 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 1 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 1 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Applicant Income Source 2

UPLOAD: Income Source Document 2
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 2 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 2 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 2 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Applicant Income Source 3

UPLOAD: Income Source Document 3
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 3 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 3 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 3 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Applicant Income Source 4

UPLOAD: Income Source Document 4
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 4 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 4 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 4 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Income Source 5

UPLOAD: Income Source Document 5*
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 5 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 5 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 5 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Income Source 6

UPLOAD: Income Source Document 6*
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 6 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 6 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 6 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Income Source 7

UPLOAD: Income Source Document 7*
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 7 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 7 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 7 (4)
(File uploads have been disabled for this form.)
Add Additional Income Source?*

Income Source 8

UPLOAD: Income Source Document 8*
(File uploads have been disabled for this form.)
Add additional documentation of this income source?
UPLOAD: Income Source Document 8 (2)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (2)
UPLOAD: Income Source Document 8 (3)
(File uploads have been disabled for this form.)
Add additional documentation of this income source? (3)
UPLOAD: Income Source Document 8 (4)
(File uploads have been disabled for this form.)

Client Needs Screener

I need help applying for SNAP (Food Stamps)/TAFDC and/or WIC*
I need help getting groceries*
I need help paying my electric, gas, oil or water bill*
I need help paying for transportation to work or medical appointments*
I need help getting affordable childcare*
I need help finding a job*
I need help filing my taxes*
I need help learning English*
I need help paying my bills*

Information Disclosure and Declaration of Accuracy

I understand that Action for Boston Community Development, Inc. (ABCD) will maintain the confidentiality of personal and financial information I provide, except that ABCD may share information with individuals within ABCD or acting for ABCD as necessary to provide services to me, to keep me updated about ABCD programs, services and initiatives and to administer its programs and ABCD may disclose information upon request of or as required by ABCD’s funding sources and/or for purposes of internal or external audits, monitoring, investigations or evaluations, and as authorized or required by law, legal process, or court order. For any other purpose, ABCD will only disclose information with my written consent.

I hereby certify that the information presented in this declaration is true and accurate to the best of my knowledge. I understand that providing false representation in this declaration may constitute an act of fraud. Further, misleading or incomplete information may result in denial or termination of services.


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