Applications and Forms

Please print and complete the following forms in order for this office to process your request for general assistance. You will need to call to make an appointment to meet with the Human Services Administrator.

  • Additional Form for Homeowner(s) - Under NH RSA 165:28, if financial assistance is granted to a homeowner, the Town of Derry is required to place a welfare lien on any property owned.
  • Application for Assistance - Please fully complete the form and call (603) 432-6753 for an appointment.
  • Contact Sheet Form - Please complete the first page with your household information and at the bottom please list the emergency need. The second page is the release form. All household members over the age of 18 need to sign and date the form in order for this office to verify information and contact other agencies on your behalf.
  • Family Financial Affidavit Form - Under NH RSA 165:19, the applicant's father, mother, stepfather, stepmother, son, daughter, husband, or wife is required to complete this form to determine their ability to financially assist the applicant.
  • Required Verifications Checklist - Please bring in the verifications that apply to your household. Some verifications will not apply in every case.