Town of Mansfield Fee Waiver

HOW TO APPLY
Please complete this online application and provide copies of the documents listed below.

Any questions can be directed to
Cathy Pomerleau
(860) 429-3315
human.services@mansfieldct.org

Income Limit Guidelines and Annual Cap per Household

Effective July 1st, 2025 to June 30th, 2026

Household Size	25% Fee Waiver	50% Fee Waiver	75% Fee Waiver	Annual Cap Per Household
1	$70,950	$44,350	$26,600	$431
2	$81,050	$50,650	$30,400	$861
3	$91,200	$57,000	$34,200	$1,292
4	$101,300	$63,300	$38,000	$1,722
5	$109,450	$68,400	$41,050	$2,153
6	$117,550	$73,450	$44,100	$2,583
7	$125,650	$78,500	$48,650	$3,014
8+	$133,750	$83,600	$54,150	$3,444

"Extremely Low" is 30% of median income in Mansfield and is reflected in 75% column

"Very Low" is 50% of median income in Mansfield and is reflected in 50% column

**HUD’s 2024 calendar year data will be used for July 1, 2025 - June 30th, 2026 Fee Reductions, HUD’s 2026 calendar year data will be used for July 1, 2026-June 30th, 2027 Fee Reductions etc.**

Please note the following documentation will be needed to process your application:

Proof of Residency of ALL persons who reside in the household. Applicants must reside in Mansfield for more than six months during the course of the year.Three (3) most recent pay stubs for all income earners in the household.Copy of other sources of income (if applicable) i.e.: Social Security, Private Pension, Unemployment & Workman's Comp, Disability Benefits, Veterans Benefits, Rental Income, Welfare, Alimony, Child Support, etc.Copy of your most recent federal tax return for each adult in the household.Copy of your most recent bank statement for each adult in the household.

Applicant's Name*

First NameLast Name

Date of Birth*

Email*

example@example.com

Co-Applicant's Name

First NameLast Name

Date of Birth*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Applicant's Employer

Employer

Street Address

CityState / Province

Postal / Zip Code

Co-Applicant's Employer

Employer

Street Address

CityState / Province

Postal / Zip Code

Other Sources of Income

Additional household members*

	Relationship to applicant	Date of birth	Employer	Yearly Income
Name of household member
Name of household member
Name of household member
Name of household member
Name of household member
Name of household member
Name of household member
Name of household member
Name of household member

*Eligibility is based on the combined income of all household members listed on the application.

PENALTY FOR FALSE OR FRADULENT STATEMENT;U.S.C Title 8, Section 1001, provides; “Whoever, in any matter within the jurisdiction of any Department or Agency of the United States knowingly and willfully falsifies or makes any false, fictitious or fraudulent statements of representation, or makes or uses any false writing or document knowing the same to contain any false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both.”

I hereby apply for a fee reduction and certify the accuracy of the information contained herein in accordance with all provisions of the law and agree to notify the appropriate town department in writing in the event of changes in said information; any changes effecting your eligibility status over the course of the year must be reported to the Town so we can evaluate whether or not you continue to qualify for the waiver.

By checking this box, my household would also like to be considered for the Mansfield Farms to Family program if my application is approved. I understand I would be responsible for picking up my fresh produce and dairy products from the distribution site once a month during the harvest season.

Yes, I would like to participate

Applicant Signature

Co-Applicant Signature