AFSCME/City of Boston Housing Trust Emergency Assistance Application

City of Boston - AFSCME Council 93, AFL-CIO Housing Trust Fund

Application and Affidavit for Emergency Funds

Qualified AFSCME members in good standing who are homeowners and renters are eligible to apply for emergency loan assistance to cover housing-related expenses as outlined in the Eligibility Criteria.

Please note that emergency funds are loans, provided through the City of Boston Credit Union and repaid by the member through payroll deductions to the Credit Union.

You must be or be eligible to become a member in good standing of the City of Boston Credit union to receive funds.

Please mail or drop off this application to:

City of Boston - AFSCME COUNCIL 93, AFL-CIO Housing Trust Fund

Attention: Helen Yee

8 Beacon Street, 8^th floor

Boston, MA 02108

Date:_______________________

Name: __________________________________________________________________

City of Boston Employee ID Number (found on check stub) _______________________

Home Address: ___________________________________________________________

____________________________________________________________

Primary Phone:___________________ Home email: ________________________

Work Phone: ___________________ Work email: ________________________

Best way to reach you: ____________________________________________________

Department and Work Site: ________________________________________________

Job title: _______________________________________________________________

Current base weekly salary, excluding overtime: ________________________________

In the past, have you received assistance from the Trust?

No ___________

Yes___________

If yes, when did you receive assistance?

________________________________________________________________________________________________________________________________________________________________________________________________________________________

For what purpose? (circle one) Rental or Emergency or 1^st time Homebuyer

Are you still repaying the Credit Union for a Trust assisted loan?

No ___________

Yes __________ If yes, this debt must be repaid before you submit an application for additional funds. And you may only receive a total of 2 Trust loans in a 3-year period.

What is the emergency reason that you are having difficulty paying any of the above bills: (check all that apply)

Unexpected emergency household repair, such as boiler, furnace, etc.(please explain:____________________________________).

Unexpected loss of household income due to illness of yourself or of another person in your household who helps to pay the household expenses

Unexpected loss of household income due to loss of a job by another person in your household who helps to pay the household expense

Unexpected loss of income that you expected to get from tenants

Other: explain nature of the emergency in detail:

___________________________________________

Date of emergency: ____________________________

Amount requested: $________________ (up to a maximum of $ 2000)

ATTACH: Appropriate documentation, e.g., a bill, a contractor quote or other repair estimate, if applicable. Further documentation may be required.

ATTACH: Your most recent pay stub.

ATTACH: Your "member in good standing letter" received from AFSCME Council 93 or your Local President or delegate, and issued within the past six months.

The undersigned hereby certifies to the Trust that the preceding information is accurate, truthful, and correct, and acknowledges that the Trust is relying upon this certification to provide Trust funds.

Default of this loan prohibits the undersigned from receiving any other benefits from the Trust.

I understand and agree to repay the loan in its entirety regardless of my employment status with the City of Boston.

I agree to repay the loan through payroll deduction as long as I am employed by the City of Boston.

I understand and agree that the Credit Union can share any information, notices and/or documentation associated with the member's Trust assisted loan.

I agree to hold harmless and indemnify the Trust and the Trustees for any false or misleading statements or representations made in my application to the Trust and/or to the Credit Union.

Signature of Applicant: _____________________________________

For Trustee use only:

Reviewed by: ____________________________

Date: ____________________________

Approved by Trustees on _____________________ (date)

Not approved by Trustees on _________________ (date)

Commitment letter sent on ____________________ (date)