Application for Emergency Financial Assistance

Applicant: After completing the form a social worker from the Human Services Department will contact you to complete the remainder of the application.

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 Social Worker.

Application Process

A Human Services Department 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.

Demographics and Reason for Need (to be completed by applicant):

Phone Number:

Email:

Length of Residency in Lexington in Years/Months:

Years *

Months (if needed) *

Residency Type:

Owns

Rents (Market Rate)

Rents (Affordable/Subsidized)

Homeless

List all people in the Household with Dates of Birth:

Do you need to add more household members?:

Yes

Do you need to add more household members?:

Yes

Additional household members? List here:

Amount Requested (Subject to funding limits):

Requested for? Select all that apply:

Rent/mortgage

Utilities

Car repairs/insurance/payment

Medical

Groceries/Food

Cable/Internet

Phone

Describe why Financial Assistance is needed at this time:

Other funding sources already utilized/sought:

Comments:

Upload File(s): 2 months of the most recent bank statements (proof of income if no direct deposit)

Click Here to Upload

Upload File(s): Proof of residency (driver’s license, utility bill, rental agreement). Must be a resident for at least 12 months to be eligible for financial assistance

Click Here to Upload

Upload File(s): Proof of emergency and/or overdue expenses

Click Here to Upload

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

Monthly Income Information:

Employment Income (incl. self-employment):

Disability/Assistance Income (SSDI, AFDC/TAFDC, EAEDC):

Retirement Income/Source(s):

Other Pensions and Retirement Allowances (incl. spousal benefit, etc.):

Unemployment:

Veteran’s Benefits/Pension:

Worker’s Compensation:

Net Profit from Business/Interest/Dividends:

Rental Income:

Alimony/Child Support:

Other:

Total Monthly Income:

Monthly Expenses:

This section is required. If an expense is not applicable simply type in "0" (zero).

Rent/Mortgage:

Homeowners Insurance/Renters Insurance/Property Taxes:

Groceries/Food:

Cable/Internet:

Car (incl. payment, insurance, maintenance, gas):

Utilities (Electric, Gas, Oil, etc.):

Water/Sewer:

Phone (Cell, home):

Child Support:

Other (transportation, fitness, misc.):

Total Monthly Expenses:

Signature

First Name

Last Name

Choose how to sign

Draw Type

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.