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Longmeadow, MA

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Application Chapter 115 Benefits

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Steps

1. Applicant Info This section is complete This section is incomplete
2. Veteran Information This section is complete This section is incomplete
3. Applicant Employment This section is complete This section is incomplete
4. Shelter Info This section is complete This section is incomplete
5. Automobiles This section is complete This section is incomplete
6. Obligations This section is complete This section is incomplete
7. Investments This section is complete This section is incomplete
8. Life Insurance This section is complete This section is incomplete
9. Life Insurance Continued This section is complete This section is incomplete
10. Medical Insurance This section is complete This section is incomplete
11. Medical Insurance Continued This section is complete This section is incomplete
12. Upload Any Files You May Have This section is complete This section is incomplete

Applicant Info

Applicant Information
This can be the veteran or qualifying dependent.
First Name*
Middle Initial
Last Name*
Jr/Sr Sfx.
Phone Number*
Date of Birth*
Date of Birth
Relation To Veteran*
Applicant Sex*
Street Number*
Street Name*
Street Type*
Apt #
City*
State*
Zip Code*
Are you a citizen*
Continue

Veteran Information

Veteran Information
First Name*
Middle Initial
Last Name*
Jr/Sr Sfx.
Phone Number*
Date of Birth*
Date of Birth
Street Number*
Street Name*
Street Type*
Apt #
City*
State*
Zip Code*
Branch of Service*
Service Date Start*
Service Date Start
Service Date End*
Service Date End
Continue |Go Back

Applicant Employment

Applicant Employment
If retired please input last employer
Last Employer*
Occupation*
Months Employed*
Street Number*
Street Name*
Street Type*
Apt #
City*
State*
Zip Code*
Self Employed?*
Reason For Application*
Continue |Go Back

Shelter Info

Shelter
Does The Applicant Own a Home*
Date of Original Mortgage
Date of Original Mortgage
Original Mortgage Amount
Current Mortgage Balance
Is This a Mutiple Family Building
Monthly Income From Property
Do You Have a Second Mortgage or Equity Line
Have You Sold or Transferred Any Real Estate Within The Last 36 Months
Dates Property Was Sold
Dates Property Was Sold
Do You Pay For Any of The Following
Heating/ Air conditioning Separate from Rent *
Electricity or Gas for Cooking*
Telephone or Cellular Phone*
Continue |Go Back

Automobiles

Autos
Number of Vehicle in Household, Year, Make, Model. Registration Number and State of each vehicle. List all vehicles even if not registered.
List all vehicles even if not registered. If none enter NA
Continue |Go Back

Obligations

Obligations
Is Applicant obligated to pay support?*
Is Applicant in arrears for any support payments?*
Is Applicant currently in receipt of any other public assistance from any other sources?*
Has Applicant received or is receiving C.115 benefits from any other community?*
Continue |Go Back

Investments

List the Name, Account Number(s), and current Value of all IRAs, Savings Bonds, Money Market Accounts, CDs, 401K accounts, or any other type of savings, investment or retirement account of any kind.*
If none enter NA
Has Applicant transferred any Bonds, Bank Books, or any amount of Money; made an irrevocable beneficiary on any insurance or assigned any insurance; do you have a joint account with any other person; created any real property trusts, living wills, etc.?*
List all outstanding creditors and amounts owed, including any personal loans.*
If none enter NA
Give full details of all bank withdrawals in the past 12 months other than monthly living expenses.*
If just living expenses enter NA.
Continue |Go Back

Life Insurance

Life Insurance*
If yes list details below
Continue |Go Back

Life Insurance Continued

Name of Insured*
Amount*
Monthly Premium*
Policy Number
Beneficiary *
If this page is blank you have indicated you have no life insurance. Please select next page.
Continue |Go Back

Medical Insurance

Does the Applicant or Spouse have medical insurance?*
This does not include medicare.
Continue |Go Back

Medical Insurance Continued

Company Name*
Insurance Type*
Premium*
Medicare A?*
Effective Date
Effective Date
Medicare B?*
Effective Date
Effective Date
Prescrip. Drug Plan*
Plan Name
Cost Per Month
Prescription Advantage*
Low Income Subsidy?*
Continue |Go Back

Upload Any Files You May Have

Upload any files you have.
Upload any of the following: Mortgage Statements, Rent Receipts, Water/Sewer Bills, Three Months Bank Statements, Authorization for release of information, Agreement to reimburse, DOR form, and any other files you may deem necessary to make a decision for your request.

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1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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The Town of Longmeadow
20 Williams Street
Longmeadow, MA 01106
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