Assistance


Senior Needing Assistance

Name:*
Date of Birth:*
Address:*
Home Phone:
-

Income level

Please check the monthly income level that applies to you

Monthly Income Level:*

Asset Level (Cash Assets)

Select:

If requested, are you willing to provide documentation to prove eligibility for requested assistance or service?

Please Chose One:

Area of needs

Area of Needs:

Please explain your situation to help us better understand how to serve you? Include any preferences for a preferred provider or agency for assistance requested.

Please Explain:

Have you sought assistance from or are you currently receiving assistance from another organization? If yes, please list here

Please List:

Contact information of family member, caregiver, or professional making request; if applicable.

Contact Name:
Contact Address:
Contact Home Phone:
-
Contact Work Phone:
-
Contact E-mail:

Agreement and signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if accepted as a recipient of assistance, any false statements, omissions, or other misrepresentations made by me on this application may result in loss of future assistance from SOAR.

Our Policy

It is the policy of SOAR, Supporting Older Adults through Resources, Inc. to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. SOAR is a registered 501 © 3 nonprofit organization established to offer assistance to Frederick County seniors aged 65 and above.

We are honored to be able to give your application consideration and will respond to you as soon as possible.