W-137A Form: Request for Emergency Assistance

In Section I, Emergency Assistance, enter the type of emergency assistance you are requesting and the reason you need emergency assistance.

In Section II, Additional Allowances, mark each allowance you are requesting for special need(s): Back rent, Repair of essential household items, Back mortgage and/or taxes, Pregnancy allowance, or Restaurant allowance because I cannot prepare meals where I am living.

Also mark Additional allowance for fuel, Property repairs, Replacement of clothing lost as a result of a disaster such as homelessness or fire, or Other:.

Burial allowance: you or your duly authorized representative must apply for this allowance at the Office of Burial Services, 33-28 Northern Boulevard, 3rd Floor, Long Island City, NY 11101, Telephone: 718-473-8310.

For expenses related to moving, mark Moving expenses, Furniture and other household items, Security deposit/agreement, Storage of furniture and personal belongings, or Broker's/finder's fee/voucher, and enter the New Address (include apartment number).

Enter the City, State and Zip Code, then fill in When did you move?, enter the New rent, the Landlord's name, the Primary tenant's name, and the Address (include apartment number), City, State and Zip Code.

In Section III, Work Activity-Related Supportive Services, mark what you are requesting: Clothing for participants in job search activities who have exceptional circumstances, such as homelessness or a recent fire and lack of appropriate clothing, or Activity/engagement-related licensing, uniform or durable goods fee within approved limits, upon submission of documentation certifying the need for such items.

Also mark Child care allowance within approved limits, if needed, Necessary public transportation, or Other work activity-related supportive services:.

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.

In Section IV, Add Person to Case, mark each person you want to add to your cash assistance case: New Baby, Child entered home, Child under 18 years of age (whose immigrant status has changed since my last application/recertification), or Spouse/Adult living with me who has not previously applied (this person must complete an application to receive assistance).

Also mark Spouse who previously applied and was denied because of immigration status and his/her status has changed now, Myself/Adult payee to the case, or Other.

For each one, enter the Name, Date moved in/returned, Date of Birth and Social Security Number (if known).

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

Sign on the Participant's Signature line, then enter the Date of Request and the Time of Request, and mark AM or PM.

Form W-137A is the Request for Emergency Assistance, Additional Allowances, or to Add a Person to the Cash Assistance Case, for participants only. For participants only: fill out this form if you need emergency assistance, additional allowances, or to add a person to the case.