Fillable Formal Application FEE $10 Applicant Information

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Formal Application FEE $10 Applicant Information

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1
Elderly or Disabled Living
Formal Application FEE $10
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
City
State
Email
$
Phone:
Desired Amount:
Please explain your
situation:
YES
NO
If no, are you authorized to work in the U.S.?
YES
NO
YES
NO
YES
NO
YES
NO
YES NO
YES
NO
YES
NO
YES
NO
YES
NO
YES NO
Are you a citizen of the
United States?
Are you on SSI or SSDI?
Are you retired?
Do you have children?
Have you reached out to other nonprofits?
Do you have a mental illness?
Has COVID-19 affected your life?
Do you need help with utilities?
Do you need help with moving expenses?
Have you ever been convicted of a felony?
If yes, explain:
Mailing Address:
P.O. Box 821177
North Richland Hills, TX 76182
EMAIL:
info@elderlyordisabledliving.com
List mental illness:
Utility provider
(s):
Destination:
To/From
Medication(s) Cost
Per Month
Medical Bill cost
Per Month
Do you use your
local food bank?
2
Education
High School:
From:
To:
Did you graduate?
YES
NO
Diploma:
College:
From:
To:
Did you graduate?
YES
NO
Degree:
Other:
From:
To:
Did you graduate?
YES
NO
Degree:
Previous Employment
Company:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES
NO
Company:
Job Title:
Responsibilities:
From:
To:
Reason for Leaving:
May we contact your previous supervisor for a reference?
YES
NO
Military Service
Branch:
From:
To:
Rank at Discharge:
Type of Discharge:
If other than honorable, explain:
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.
Signature:
Date:
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Formal Application FEE $10 Applicant Information

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Completed 23 September 2021

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