JOSH BRESSETTE COMMIT TO SAVE A LIFE INC.

2345 Skiparee Rd North Pownal VT 05260

413-749-5007

APPLICATION FOR HEROIN/OPIOID RECOVERY SERVICES

*while we would love to help in the recovery from all forms of addiction, our mission is to aid and assist in the recovery from heroin and other opioids drugs, only.

Information provided in this application is strictly confidential and used for the purpose of providing assistance only.

NameDate

Address

Telephone Date of Birth

Reason you are applying for services:

Drug(s) you are in recovery from:

Length of time you have been using this drugDate of last use

Do you have insurance?Yes_____ No______

If no, are you eligible for MA Health or Medicaid?

If yes, which insurance do you have?

Have you completed a detoxification program? Yes_____ No ______

If yes, where?

Are you currently employed? Yes_____ No______Full Time______or Part Time______

Name and Address of employer?

Would you be willing to volunteer your assistance in future fundraising events held by Josh Bressette Commit To Save A Life?

In the following sections please fill out only the part(s) for which you are applying for assistance:

Are you applying for assistance to get into a detox facility?

If yes, which facility (if known)

Will you need transportation to this facility?

Are you applying for transportation assistance to a clinic or other facility?

If yes, to where?

Frequency of service

Contact person at clinic or other facility

Are you applying for rent assistance at a sober living facility?

If yes, name of facility

Address of facility

Contact person at facility

Rent amount (weekly or monthly) ______does this include meals? Yes___ No___

Are you applying for payment of services at a clinic or Doctor’s office?

If yes, name of facility

Address of facility

Contact person at facility

Fee’s (weekly or monthly) ______One-time fee? ______

I hereby certify that I am unable to pay for the services requested at this time. Please Initial ______

Please Sign Here Date

Josh Bressette Commit To Save A Life Inc. is a nonprofit organization exempt from federal income tax as described in Section 501(c) (3) of the Internal Revenue Code; EIN # 47-1129831.

INCOME & DEMOGRAPHIC SURVEY FORM

SECTION 1: Family Size:Total number of persons residing in the dwelling as their primary residence

SECTION 2: Income: Gross Annual Household Income is defined as the combined yearly gross income of all persons living, or expecting to live in, that are 18 years or older except full-time students, each residential unit at the time of this Survey. Yearly gross income is gross monthly income multiplied by 12. Gross Monthly Income is the sum of monthly gross pay; any additional income from all sources, both taxable and nontaxable income including, but not limited to any of the following; earnings, overtime, part-time employment; bonuses, dividends, interest, annuities, pensions, Veterans Administration compensation, gross rental or lease income, commissions, deferred income, welfare payments, public assistance, sick pay, unemployment compensation and income received from trusts from business activities and investments.

Given the above definition of Gross Annual Household Income, please refer to the corresponding column for the total number of persons residing in your home as checked off in Section 1 above, and the please circle the box that pertains to your situation in the past year (12 months). Circle only ONE box.

Family Size & Income Table

Family Size / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
Greater than $46,000 / Greater than $52,600 / Greater than $59,150 / Greater than $65,700 / Greater than $71,000 / Greater than $76,250 / Greater than $81,500 / Greater than $86,750
Equal to/less than $46,600 & Greater than $29,150 / Equal to/less than $52,600 & Greater than $33,300 / Equal to/less than $59,150 & Greater than $37,450 / Equal to/less than $65,700 & Greater than $41,600 / Equal to/less than $71,000 & Greater than $44,950 / Equal to/less than $76,250 & Greater than $48,300 / Equal to/less than $81,500 & Greater than $51,600 / Equal to/less than $86,750 & Greater than $54,950
Equal to/less than $29,150 & Greater than $17,500 / Equal to/less than $33,300 & Greater than $20,000 / Equal to/less than $37,450 & Greater than $22,500 / Equal to/less than $41,600 & Greater than $24,950 / Equal to/less than $44,950 & Greater than $28,440 / Equal to/less than $48,300 & Greater than $32,580 / Equal to/less than $51,600 & Greater than $36,730 / Equal to/less than $54,950 & Greater than $40,890
Equal to/less than $17,500 / Equal to/less than $20,000 / Equal to/less than $22,500 / Equal to/less than $24,950 / Equal to/less than $28,440 / Equal to/less than $32,580 / Equal to/less than $36,730 / Equal to/less than $40,890

SECTION 3:Other Household Information – Given the total number of individuals in your home, please break down this total pursuant to the following demographic types of information requested

Beneficiaries (actual individuals served by program)
Income
“Extremely Low”
(</= 30% median) / "Very Low"
(31%-50% of median) / "Low"
(51%-80% of median) / Over Income
(>80%)
RACE
White
Black/
African American
Asian
American Indian/ Alaskan Native
Native Hawaiian/ Other Pacific Islander
American Indian/ Alaskan Native & White
Asian & White
Black/African American & White
American Indian/ Alaskan Native & Black/African American
Balance/Other
Total
Hispanic included in “Total”
Female-Head of Household
Handicapped/Disabled
Elderly (60+)

SECTION 4:Other Household Information – Please respond to the 3 questions below (answer may be zero)

a) Is this a Female-Headed household?_____ Yes_____ No

b) Number of Elderly (60 +) in household?_____

c) Number of Handicapped/Disabled in household:_____

SECTION 5: Signatory Verification *

The potential beneficiary of this program, or applicant, certifies that I/we am/are local residents within the City of North Adams, and that all information furnished herein for the purpose of receiving the programmatic assistance from this respective social service agency true and accurate, and signed so under the pains and penalties of perjury.

______

Head of HouseholdDATE

* The applicant hereby also acknowledges that this program is subject to the on-site inspection of programmatic and fiscal related in-take forms for all participants as may be funded with federal CDBG moneys, and that said representatives of the City of North Adams and/or said funding source have the right to inspect said clientele files in order to confirm certain performance measures but shall do so with complete client confidentiality.

I:\CDF_2017\Social Services\Low_Income_Survey_Form_FY17.DOC