General Assistance | Referral | Advocacy

General Assistance Forms

STATE OF MAINE DHHS FORMS

GA Reimbursement Form (Word)

State of Maine Substitute W-9 & Vendor Authorization Form GA Reimbursement Form (PDF Fillable)

Emergency Assistance Information and Application

GENERAL ASSISTANCE APPLICATION AND SUPPORTING FORMS (APPROVED BY THE STATE)

GA Application and Instructions (PDF Fillable) – State of Maine

GA Application and Instructions (Word Non-Fillable) – State of Maine

Eligibility Form

Ineligibility Form

Please note that these forms below are provided solely as a training resource and are not a substitute for consultation with your own City/Town Attorney on any legal question. Most forms are in Microsoft Word and ones in PDF will be labeled.

APPLICANT

Applicant Authorization of Disclosure Consent Form – Sample MMA

Applicant Consent to Release – Sample Bangor

Applicant Guidelines – Sample Bangor

Applicant Notice and Requirements – Town of Rockport

Applicant Release for Confidential Information (PDF) – Sample MMA

Application Appointment Checklist – Sample Kennebunk

General Assistance Frequently Asked Questions

Application Appointment Information – Sample South Portland

BURIAL

Burial/Cremation Application – State of Maine

Burial/Cremation Application (same as GA) – State of Maine

Burial/Cremation Application Information – Sample Lewiston

Burial/Cremation Family Member Information – Sample Lewiston

Burial/Cremation Bank Letter – Sample Biddeford

Burial/Cremation Financial Statement – Sample Biddeford

Burial/Cremation Financial Statement – State of Maine

DISQUALIFICATION

Disqualified Proration Form

Disqualification Check List for DHHS - FILLABLE

EMPLOYMENT

Employer Form – Sample Biddeford

Employment Search Guidelines – Sample Biddeford

Employment Search Verification – Sample Biddeford

FAIR HEARING

Fair Hearing Request – Sample Biddeford

Fair Hearing Notice – Sample Biddeford

Fair Hearing Checklist – Sample Biddeford

Fair Hearing Decision (PDF) – Sample MMA

FRONT DOOR NOTICE (REQUIRED BY LAW)

Front Door Notice – Sample Union

Front Door Notice – Sample Biddeford

HOUSING

Motel Agreement Template

Housing Search with Consent

LANDLORD

Landlord Form – Sample Biddeford

Rental Information-Agreement – Sample Bangor

LUMP SUM

Lump Sum Excel Calculation Sheet

MEDICAL

Medical Form – Sample Biddeford

Medical Form – Sample Bangor

Request for Confidential Medical Information (PDF) – Sample MMA

POVERTY TAX ABATEMENT

Application for a Property Tax Abatement

Executive Session Notice to Applicant Regarding Poverty Abatement Hearing

Agenda for Board of Selectmen Poverty Abatement Appeal

Door Posting regarding Executive Session

Opening Remarks Board of Selectmen Meeting Regarding Poverty Abatement

Motions for Poverty Abatement Application

Memo to Board of Selectmen regarding Overview of Process

Town Staff Financial Analysis of Poverty Abatement Application Template

Poverty Tax Abatement Notice of Decision

REPAYMENT

Repayment Agreement – Sample Scarborough

Repayment Payment Schedule – Sample Scarborough

TOWN/CITY EMPLOYEE FORMS

General Assistance Administrator Confidentiality Statement – Sample MMA

Employee Confidentiality Form – Sample Rockport

VOUCHERS

Food and Personals Allowable List – Town of Rockport

Voucher Guidelines – City of Biddeford

WORKFARE

Workfare Volunteer Hours Timesheet