Application

John A. Henry Trust
Town of Provincetown

The John A. Henry Trust provides funds to assist eligible Provincetown children. 
To qualify for assistance the child must:

• be between the ages of 0 - 18 years
• be a year-round resident of Provincetown
• demonstrate a need for financial assistance including, but not limited to:
  temporary housing and shelter assistance, prescription drugs, dental and vision care/transportation to and from medical and dental apppointments (accompanied by parent or guardian), assistance in locating and paying for childcare.

Children from low and moderate income families who are eligible for any of the following programs are automatically eligible for services under the trust fund:

1. WIC (Women, Infants, and Children Supplemental Nutrition Program)
2. Mass Health
3. Federal School Lunch Program
4. Food Stamps

Applications may be submitted at any time.  Completed forms may be mailed to:

John A. Henry Trust
c/o  Cape Cod Children's Place
P.O.Box 1935
North Eastham, MA  02651
Attn. Charlotte Fyfe

OR
Your application may be dropped off any Tuesday between 1:00 - 5:00 pm at:

The Provincetown Family Resource
Grace Gouveia Building, Room 14 (second floor)
26 Alden Street
Provincetown, MA 

Your application should include proof of famly income:  1 month's pay stubs, or, if self employed, a copy of the most recent year's tax return or proof of participation in one of the above programs and   proof of residencey  (a driver's license, rental agreement, physical custody award, utility bills).

Applicants should expect a decision to be made on their application within ten days of submission.

IF YOU HAVE QUESTIONS, NEED HELP IN FILLING OUT THIS FORM, OR WOULD LIKE TO CHECK THE STATUS OF YOUR APPLICATION, PLEASE CALL CHARLOTTE FYFE AT 508-237-2688 (CELL).

Your application is confidential.

APPLICATION

JOHN A. HENRY TRUST
Town of Provincetown & Cape Cod Children's Place, Inc.

Name:_______________________________________________D.O.B.____________________________

M or F                    In School?  Grade & School:_________________________________________________

Address:________________________________________________________________________________
              ________________________________________________________________________________

Same as Mailing Address?:__________________________________________________________________
                                         __________________________________________________________________

Telephone:_________________________________________________________

Parent or
Guardian:_______________________________________________________________________________

Same Address &
Tel. # as Child?:__________________________________________________________________________
                         __________________________________________________________________________

Family size:_______________________________Gross Family Income:_______________________________

Referred by:_________________________________________________________________________________

Briefly describe the amount of assistance you are applying for and the reason for your application.  Use the back of this form, if necessary.
All information is kept strictly confidential.

I verify that the information contained above is correct and true to the best of my knowledge.

Signed:___________________________________________Date:__________________________________

JOHN A. HENRY TRUST
APPLICATION

Page 2

What is the name, arddress and telephone number of the program, person or service you would like funds paid to? ___________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

-----------------------------------------------For Office Use Only -------------------------------------------------

Date Application Received: _____________

Proof of Residency:___________                                             Proof of Income:________________

Date Reviewed: ____________

Request Approved?
Yes __________________ Amount ___________________________

No __________________