The SWAN Society Emergency Grants

The SWAN Society Emergency Grants is sponsored by The SWAN Society. Provides one-time, emergency grants to single, divorced, or widowed women aged 65 and over who live within a 25-mile radius of Boston.

## Application for Assistance ## SWAN Society in Boston, Inc. ## (formerly the Widows’ Society in Boston) ## swansocietyboston@gmail. com Since 1816, the SWAN Society in Boston, has been giving personal and financial support to elderly widows and single women with the goal of helping women to remain independent in their own living space for as long as possible.

Criteria for assistance are: -Being single (widowed, divorced, never married) -Living within 25 miles of Boston Grants are for one-time, specific needs and not for ongoing expenses. After the form is received, the Executive Director will review the application with the Board of Directors. Once the application has been reviewed, the referring contact will be notified of our decision usually within a 2-3 week period.

Referring Agency Information: Monthly Income: $____________ Source(s) of Income: ____Salary ___Social Security ___Disability ___ Pension ___Other Assets: Savings $____________ Securities $__________ Other $______________ > Agency Name: Person Referring: > Phone Number: Email Address: > Applicant Name: Date of Birth: > Address: Is applicant single (widowed, divorced, or never married)?

Please explain below the purpose of the financial assistance requested. If it is to assist with an arrearage or debt, please explain how the applicant accrued the debt and steps to ensure the applicant will not incur debt going forward. If you need more space, please attach additional pages.

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Amount Requested: $___________________________ Have you applied for assistance from other agencies?

_______________________________________ If yes, when and for what purpose? What were the results? ____________________________________________________________________________ ____________________________________________________________________________ If assistance is granted, to whom should the check be made out?

________________________________ Additional comments or information: ____________________________________________________________________________ ____________________________________________________________________________ I have read and understand this application. I declare that the statements contained and information furnished by me in this application are true.

I also acknowledge that if I am approved for an emergency grant, it will be on a one-time basis only. The Board of SWAN Society in Boston, Inc. and their agent are authorized to verify any and all information contained within this application. Applicant Signature ___________________________________________________________ Date _____________________________________________________________________