5-Town Assistance Form

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An email and phone number is required to fill out this form. If you do not have either of these, please call Merkeisha for assistance: (617) 923-3505 x207

Please note that this application can be saved and finished later
Client and Household Information

Street Address (if homeless please write 'homeless')

i.e. 123-456-7890

i.e. 01/05/1974

Enter your income with no dollar sign, commas, or decimals

Housing Information

Enter amount with no dollar sign, commas, or decimals

Enter amount with no dollar sign, commas, or decimals

Housing Problems

Behind on Rent

Enter a number with no dollar sign, commas, or decimals

In order to best help you, we many need to contact your landlord to explain the rental assistance programs.  

Landlord Information

i.e. 000-000-0000

Housing Search / Moving

Public Housing
Public housing often has long waiting lists, but is worth applying for if you are eligible and do not anticipate being able to afford regular housing in the long term.

Household Finances
In order to match you with available resources, please share information about your financial situation.  

How much money do you have in cash, savings or certificates of deposit?

Job Help

Mental Health
Over the last 2 weeks, how often have you been bothered by the following problems related to housing or financial difficulties?

Financial Management Help

Voter Registration

Please upload your ID in order to be considered for our Back to Work Grant or  Tenant Assistance Fund.