Eastern Pequot Tribal Nation P.O. Box 208 North Stonington Ct 06359 Application for Emergency Assistance Date: ____________ Name (print) _________________________________________ Address: ______________________________________________________________ ______________________________________________________________ __________________________ Date of Birth: _____________ Phone # ( ) _____-_______ E-MAIL Address: ________________________________________ Date funds are needed: _____________ Total $ amount requested: _________ (Applicants are awarded $200 per calendar year) Have you attempted to obtain assistance from your local community services? Yes or No (circle one) Reason for request of funds (please explain) If more explanation is needed, please use back of form. ______________________________________________________________ ______________________________________________________________ __________________________ Please provide the name and address of the company (s) to whom the checks will be mailed. (Example: CL&P, Doctor, Landlord Etc.) ** Please include a copy of current bill** _________________________________________________________________________ _________________________________________________________________________ ____________________________ I certify that my income is $_____________ per year or that I am unemployed or retired . Applicant Signature_______________________________ Date: __________________ ==============================================================