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Get in Touch Today

For inquiries, fill out the form below.

Contact us

First name

Last name

Email*

Phone

Message*

Contact Us

136 Capitol Ave

Hartford, CT 06106

959-237-1140

Let's Connect About Your Needs

AKNEW BASIC NEEDS FORM

To request basic needs services, please fill out the application form below and allow up to 4 days for processing.

Come Visit Us

136 Capitol Ave

Hartford, CT 06106

AKNEW BASIC NEEDS FORM

To request basic needs services, please fill out the application form below and allow up to 4 days for processing.

First name*

Last name*

Are you a U.S. citizen?

Yes

Last Four of SSN*

Date of Birth *

Month

Day

Year

Please specify ethnic background or cultural identity:

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Phone*

Email*

Request Type: Please provide detailed information about why you are requesting assistance.

Basic Needs

Referral

Gift Card

Amount being requested:*

What are the funds going to be used for?*

Do you currently work?*

If you answered yes above, where do you currently work?*

Have you received funding from any other organizations?*

If you answered yes above, please write below who provided the funding and how much was provided?

What is your monthly income*

Are any household members currently enrolled in school?*

Yes

Household Member One

Is this household member a U.S. citizen?

Yes

Last Four of SSN

Please specify the ethnic background or cultural identity for household member:

Household Member Two

Is this household member a U.S. citizen?

Yes

Last Four of SSN

Please specify the ethnic background or cultural identity for household member:

Household Member Three

Is this household member a U.S. citizen?

Yes

Last Four of SSN

Please specify the ethnic background or cultural identity for household member:

Household Member Four

Is this household member a U.S. citizen?

Yes

Last Four of SSN

Please specify the ethnic background or cultural identity for household member:

Do you receive Unemployment assistance? If so please provide the monthly amount received.

Do you receive SSI assistance? If so please provide the monthly amount received.

Do you receive Saga assistance? If so please provide the monthly amount received.

Do you receive TANF assistance? If so please provide the monthly amount received.

Do you receive SNAP assistance? If so please provide the monthly amount received.

Do you receive Child Support assistance? If so please provide the monthly amount received.

By signing below, you are consenting that the information you provided in this application are true. If we discover that anything in this application is not true, we have the right to deny services. Please click the check box to acknowledge statement.

Click here to acknowledge the AKNEW Disclosure Statement.

Signature

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Home
About Us
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