Application for Financial Assistance
 Mad River Valley Community Fund
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What is your full name?
What is your home address and how long have you lived there? If less than 3 years, where were you prior?
Who shares your home with you? Names and ages please.
What is your phone number?
What is your email address?
Where do you work and how long have you worked there?
Who is your employer and what is their phone number?
Where does your partner work?
What is your gross  monthly income (total income earned before deductions) from all sources? Please identify the sources: employment, social security, unemployment, pension, dividends, alimony, child support  
What is your partner's gross monthly income?
What is the value of your assets?  Please list real estate, vehicles, boats, savings accounts, retirement accounts or other items of value.
How much debt do you have?  Please list balances on car loans, mortgages, credit cards, educational and medical debt.
What are your monthly housing expenses? Please list cost of mortgage, home insurance, property taxes or cost of rent and rental insurance.  Please indicate if you have a section 8 voucher or subsidized housing.
What are you monthly utility costs?  Please list your average monthly costs for electricity, heat, water, phone, and internet.  Please indicate if you have heating assistance, lifeline or discounts on your electric bill.
What are your monthly transportation costs? Please list the cost of your car payment, auto insurance, car maintenance and gas.
What are your monthly food costs?  Please indicate if you use 3 squares, WIC or receive free school lunch.  
What are your monthly wellness costs? Please include cost of medical insurance, prescriptions, medical supplies, co-pays and exercise expenses.
What are your monthly child care costs.  Please list cost of diapers, childcare, child support and/or other additional expenses.  Indicate if you receive any child care subsidy assistance.
What are you monthly pet care costs?  Please list food and medical expenses.
What are your monthly debt costs?  Please include payment amounts on credit cards, school loans, personal loans and educational loans.
What is the total amount that you are requesting assistance for and why? Please explain your situation and list vendors and expense.  It is MRVCF policy to make payments to vendors directly.  
If your expenses are greater than your income, what is your plan to reduce expenses or add income?  We encourage you to work with our program administrator to complete an action plan. Please call 802-461-6241
I/We authorize MRVCF personnel to verify employment and address.
I/We hereby authorize payment for any assistance granted as a result of this application to be made directly to vendors, at the discretion of the Board of Directors.  
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