137A Form PDF Details

Navigating the world of social assistance can often feel like a complex maze, especially when facing urgent need or challenging circumstances. The Form W-137A, officially known as the "Request for Emergency Assistance or Additional Allowance," serves as a crucial tool for individuals and families navigating these situations. This form allows participants in assistance programs to request urgent help—be it financial, material, or otherwise—or apply for extra allowances to cover specific needs not met by standard aid packages. From support for back rent and essential repairs to allowances for special circumstances such as pregnancy, inability to prepare meals, and even burial expenses, the form covers a broad spectrum of urgent needs. It also extends to work-related supportive services, aiming to facilitate job search activities, and provides provisions for adding new members to one's cash assistance case. With a clear understanding of what this form encompasses, individuals can take a significant step toward addressing immediate needs and stabilizing their living conditions.

QuestionAnswer
Form Name137A Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesget the w137a form, what is form 137 a, w137a, 137 a form

Form Preview Example

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Form W-137A (page 1) (LDSS-3815) LLF

Rev. 4/10/08

Date:

Case Name:

Case Number:

Caseload:

Center:

Worker Telephone No.:

FH&C Telephone No.:

Request for Emergency Assistance or Additional Allowance

(For Participants Only)

Please fill out this form if you need emergency assistance or an additional allowance.

Remember:

(1)You may be asked for proof of what you tell us. If you have trouble obtaining proof, your Worker must help you.

(2)You may still need to see your Worker. If you do, you will be given an appointment.

SECTION I: EMERGENCY ASSISTANCE

The type of EMERGENCY ASSISTANCE I am requesting is:

The reason I need emergency assistance is:

SECTION II: ADDITIONAL ALLOWANCES

I am requesting the following allowance(s) for special need(s):

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Back rent

Repair of essential household items

Back mortgage and/or taxes

Pregnancy allowance

Restaurant allowance because I cannot prepare meals where I am living

Burial allowance – you or your duly authorized representative must apply for this allowance at:

151 Lawrence Street, 5th Floor Brooklyn, NY 11201

Additional allowance for fuel

Additional allowance to maintain or restore utility service Property repairs

Replacement of clothing lost as a result of a disaster such as homelessness or fire

fec Other:

Form W-137A (page 2) (LDSS-3815) LLF

Human Resources Administration

Rev. 4/10/08

Family Independence Administration

Expenses related to moving:

New Address:

 

 

 

 

 

 

 

 

 

 

 

fec Moving expenses

 

Address (include apt. no.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

fec Security deposit/agreement

 

 

 

 

 

 

 

 

 

 

 

 

 

fec Broker's/finder's fee/voucher

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

fec Furniture and other household items

When did you move?

 

New rent: $

 

 

 

 

 

fec Storage of furniture and personal belongings

Landlord's name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary tenant's name:

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (include apt no.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

State

Zip Code

SECTION III: WORK ACTIVITY – RELATED SUPPORTIVE SERVICES

 

 

 

 

 

 

 

 

 

 

 

I am requesting the following supportive services:

 

 

 

 

 

 

 

 

 

 

 

 

 

cef Child care allowance within approved limits, if needed

cef Clothing for participants in job search activities who

have exceptional circumstances, such as homelessness or a recent fire and lack of appropriate clothing

fec Other work activity-related supportive services:

cef Necessary public transportation

cef Activity/engagement-related licensing, uniform or durable

goods fee within approved limits, upon submission of documentation certifying the need for such items

WEP agencies and/or contractors are responsible for providing necessary safety equipment or job-related clothing for their participants.

Necessary supportive services will be provided when you begin a work activity. If your needs change or if you are not receiving a needed service, you should apply for an additional allowance.

SECTION IV: ADD PERSON TO CASE

I want to add the following person(s) to my Cash Assistance case:

fec New baby

 

 

 

 

 

 

 

 

fec Adult living with me

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Name:

 

 

 

 

 

 

 

 

 

 

 

First Name

 

M.I.

 

Last Name

 

First Name

 

M.I.

 

 

Last Name

Date of birth:

 

 

 

 

 

 

 

 

 

Date moved In:

 

 

 

 

 

 

 

Social Security number (if known):

 

 

Date of birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child entered home

 

 

 

 

 

 

 

 

Social Security number (if known):

 

 

 

Name:

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

First Name

 

M.I.

 

Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date returned:

 

 

 

 

 

 

 

 

This person must complete an application to receive

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth:

 

 

 

 

 

 

 

 

 

assistance.

 

 

 

 

 

 

Social Security number (if known):

If you do not have all this information, you can still submit this form to your Worker.

fec AM cef PM

Participant's Signature

Date of Request

Time of Request

 

 

 

 

Worker's Signature

Date

 

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This PDF form will need specific information to be typed in, so be sure you take the time to enter what's expected:

1. While submitting the 137 a, make sure to complete all of the needed blank fields within the relevant area. It will help to speed up the work, which allows your information to be handled swiftly and properly.

Part # 1 in filling in w137a

2. Given that the previous array of fields is done, you're ready include the necessary particulars in The type of emergency assistance I, The reason I need emergency, and Turn page so you can proceed to the next part.

Stage no. 2 of filling out w137a

3. The following section should be fairly straightforward, Back rent Repair of essential, Expenses related to moving, Moving expenses Security, New Address, include apartment number, Additional allowance for fuel, and Furniture and other household - every one of these fields is required to be completed here.

Step number 3 in filling in w137a

4. This next section requires some additional information. Ensure you complete all the necessary fields - include apartment number, City, State, Zip Code, When did you move Landlords name, New rent , include apartment number, City, State, Zip Code, and Turn page - to proceed further in your process!

State, include apartment number, and City of w137a

It is possible to make a mistake while filling in your State, consequently make sure to reread it prior to when you send it in.

5. Lastly, this final portion is what you should wrap up prior to using the form. The fields under consideration include the next: I am requesting the following, Clothing for participants in job, Child care allowance within, Necessary public transportation, Other work activityrelated, Necessary supportive services will, SECTION IV ADD PERSON TO CASE, and If you do not have all this.

A way to complete w137a part 5

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