Application for Emergency Financial Assistance

Application for Emergency Financial Assistance

Emergency Financial Assistance is available to Lexington residents through the Lexington Emergency Assistance Fund (LEAF)
What is LEAF?

LEAF is a collection of funds specifically setup to provide financial assistance to Lexington residents experiencing an unexpected financial crisis. LEAF can provide limited financial help for critical needs when other funding sources are unavailable or have been exhausted.

To be eligible, you must:
- Be a resident of Lexington for at least 12 months.
- Provide proof of residency and income, and other information as requested to complete your application.
- Have a household income that is within these Assistance Income Guidelines (PDF).
- Develop a plan for how you will manage financial needs in the future with a Human Services Department clinical staff member.
Application Process
- A Human Services Department clinical staff member will contact you to complete a financial assessment and gather any additional documentation for the application.
- An internal team reviews each application. If approved, the situation is presented to the funding source for final approval, keeping your identity private. All decisions are made on a case-by-case basis.
- Approved funds are distributed directly to the entity requiring payment.
- The Staff member will also work with you to connect you with other supports.
If you have questions or need other help/services, contact Human Services at humanservicesoffice@lexingtonma.gov or 781-698-4840

Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I have lived in Lexington since Date*
PLEASE NOTE: To be eligible for Emergency Financial Assistance, the applicant must have lived in Lexington for at least one year.
OwnRent (Market Rate)Rent (Affordable/Subsidized)

Household Members

Please provide names and dates of birth for everyone in your household
How many persons are there in your household?*
Household Member #1*

First NameLast Name
Household Member #1 Date of Birth*

MonthDayYear
Date
Household Member #2*

First NameLast Name
Household Member #2 Date of Birth*

MonthDayYear
Date
Household Member #3*

First NameLast Name
Household Member #3 Date of Birth*

MonthDayYear
Date
Household Member #4*

First NameLast Name
Household Member #4 Date of Birth*

MonthDayYear
Date
Household Member #5*

First NameLast Name
Household Member #5 Date of Birth*

MonthDayYear
Date
Household Member #6*

First NameLast Name
Household Member #6 Date of Birth*

MonthDayYear
Date
Household Member #7*

First NameLast Name
Household Member #7 Date of Birth*

MonthDayYear
Date
Household Member #8*

First NameLast Name
Household Member #8 Date of Birth*

MonthDayYear
Date
Household Member #9*

First NameLast Name
Household Member #9 Date of Birth*

MonthDayYear
Date
Household Member #10*

First NameLast Name
Household Member #10 Date of Birth*

MonthDayYear
Date

Financial Assistance Request Information

Please provide requested information regarding your financial assistance request
Amount Requested*
Total amount of requested financial assistance (Subject to funding limits)
Rent/Mortgage/HousingCar repairs/insurance/paymentGroceries/foodPhoneUtilitiesMedical billsCable/internet
Describe why financial assistance is needed at this time*
Other funding sources already utilized/sought*
Any additional comments
Upload File(s): 2 months of the most recent bank statements*

NOTE: Screenshots or pictures are not an acceptable form of bank statement
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Upload File(s): Proof of residency (driver's license, utility bill, rental agreement, etc)*

NOTE: Applicant MUST be a resident of Lexington for at least 12 months to be eligible for financial assistance
Cancelof
Upload File(s): Proof of emergency and/or overdue expenses*

Cancelof
Please note that other documents may be requested by staff during the application process.

DO NOT upload photos of your Social Security card/number

Applicant Signature*

Clear
Legal Disclaimer

I understand that a full review of my financial need will be conducted by Human Services Department Staff before a decision is made about my application, and documentation will be required of me to verify the information I have shared herein. I understand that funds are limited and are meant for emergencies only, and that completion of this form is not a guarantee of approval. Federal Fuel Assistance Income Guidelines are used as a basis to assess eligibility for financial assistance. Other factors, such as expenses and individual need, are also taken into consideration. I authorize the Human Services Department to share information about my situation to the review team and approving authority. I understand that my identity will be kept confidential from the approving authority in order to maintain my privacy. I further authorize the Human Services Department to communicate with the entity collecting payment, as necessary, to complete this funding request. I certify that all information provided in this form is true and accurate.

After submitting this form, a clinical staff member from the Human Services Department will contact you to complete the remainder of the application.
Should be Empty:

Application for Emergency Financial Assistance

Applicant Information

Household Members

Financial Assistance Request Information

Monthly Expense Information