Respite Voucher Program Application Logo
  • Respite Voucher Program Application Form

    Aviv Older Adult Services of JF&CS
  • Thank you for your interest in the ARC JF&CS Caregiver Respite Voucher Program. Please carefully review the eligibility criteria for the program below.

     

    The Atlanta Regional Commission grant requires proof of age for both the applicant or family caregiver and care recipient (State Issued ID, State Issued Driver’s License, Birth Certificate, Passport, or Military ID). Also required is proof of residence for the applicant or family caregiver.

    Only the following proof of residence documents are accepted:

    1. Utility Bill (Electric, Gas, Water, Sanitation, Cable/Internet)

    2. Mortgage statement

    3. A rental lease and/or agreement

    4. Deed or title to home

    5. Home Owners or Renters Insurance

    6. Social Security Benefit Verification Letter 

    7. Motor Vehicle Information – (Vehicle registration or title, insurance policy or insurance card with address) 

    Please be advised that all proof of residence documentation must be dated within the last 30 days. 

    To provide valid proof of residence, we require a copy of the complete document. Please note that a photo of an envelope or just the top portion of an invoice is not accepted. The full-page document must be included to ensure all relevant information, including name, address, date and utility information is visible and verifiable.

    Please note we cannot provide funding for a loved one (care recipient) that is currently enrolled in a Medicaid waiver program (Elderly & Disabled Waiver Programs: CCSP or SOURCE). Unfortunately, these eligibility guidelines are firm, and we are not able to make exceptions. If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866. AGEWELL (1.866.243.9355).

  • Eligibility Guidelines:

    Are you a family caregiver or other informal caregiver providing care to a loved one (care recipient) under one of the following circumstances?

    • Adult family members or other informal caregivers (unpaid, non agency staff) age 18 and older providing care to individuals 60 years of age and older
    • Adult family members or other informal caregivers (unpaid, non agency staff) age 18 and older providing care to individuals of any age with Alzheimer’s disease and related disorders
    • Older relatives, including parents, age 55 and older providing care to adults ages 18-59 with disabilities
    • Paid or employeed private and/or agency staff are NOT eligible to apply as a caregiver. 
    • Reside in the 10-County Metro Atlanta Region (Dekalb, Fulton, Gwinnett, Cobb, Clayton, Henry, Rockdale, Cherokee, Douglas, Fayette)
    • The Care Recipient IS NOT enrolled in a Medicaid waiver program (Elderly & Disabled Waiver Programs: CCSP or SOURCE)
    • The Care Receiver DOES NOT reside in one of the following settings: personal care home, assisted living community, memory care community, continuum of care retirement community (CCRC), short-term rehab, skilled nursing facility/nursing home.
  • Does your loved one (care recipient) currently reside at home? I confirm they do not reside in one of the following settings: personal care home, assisted living community, memory care community, continuum of care retirement community (CCRC), short-term rehab, skilled nursing facility/nursing home?

  • If you answered Yes to all questions above, then you are eligible to apply for the Respite Voucher Program.

    Please do not apply until you are ready to schedule in-home or out-of-home respite services for your loved one.

    If you do not meet these eligibility guidelines and would like to learn more about other resources and programs for caregivers and older adults, please reach out to our AgeWell Atlanta Information and Referral line at 1.866.AGEWELL (1.866.243.9355).

  • Respite Voucher Program Application Form

  • If yes, verify that all information is current. I,  * confirm that all updated information has been included in this application.  *

  • *Please note that cleaning duties/responsibilities must be classified as light housekeeping and may only be done for care recipient

    *Please note that this grant will not pay for transportation costs (mileage will be billed directly to the family caregiver)

  • Primary Family Caregiver Information

  •  - -
  • Respite Care Recipient Information

  •  - -
  • Using the list below, please write the disability or special need in the appropriate location (if other, please specify)

    Intellectual/Developmental Disability: Intellectual Disability, Autism

    Physical/Orthopedic/Mobility Impairment: Multiple Sclerosis, Muscular Dystrophy, Cerebral Palsy

    Sensory/Communication Impairment: Blind/vision impaired, Deaf/hard of hearing

    Mental/Emotional/Psychosocial Impairment: Mental Illness, Mood/Personality Disorders

    Degenerative Neurological Impairment: Dementia/Alzheimer’s, Parkinson’s, ALS

    Neurological Impairment (nondegenerative): Stroke, Traumatic Brain Injury, Spinal Cord Injury

    Medically Fragile/Frail Elderly

    Other (please specify below)

  • Acknowledgements

    Primary Family Caregiver: Please read and initial each item below.

    Sign and date form before submitting the application
    to Aviv Older Adult Services of JF&CS.

  • Jewish Family & Career Services administers the Respite Voucher and Personal Supportive Services Program to provide short-term funding for respite care services but does not provide these services directly or indirectly. I attest that the information included in this Application Form is true and accurate to the best of my knowledge. I understand that falsification of information will result in termination of services.

  • Clear
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  • If you experience any problems with this application and/or have additional questions, please contact Shai Stallings at (770)677-9422.

  • Please provide:

    Proof of Age for both the caregiver and your loved one (care recipient): State Issued ID, State Issued Driver’s License, Birth Certificate, Passport, or Military ID.

    Proof of Address for the caregiver: The documents must show your full name and current residential address.

    The following proof of residence documents are accepted:

    1. Utility Bill (Electric, Gas, Water, Sanitation, Cable/Internet)

    2. Mortgage statement

    3. A rental lease and/or agreement

    4. Deed or title to home

    5. Home Owners or Renters Insurance

    6. Social Security Benefit Verification Letter 

    7. Motor Vehicle Information – (Vehicle registration or title, insurance policy or insurance card with address) 

    Please be advised that all proof of residence documentation must be dated within the last 30 days. 

    To provide valid proof of residence, we require a copy of the complete document. Please note that a photo of an envelope or just the top portion of an invoice is not accepted. The full-page document must be included to ensure all relevant information, including name, address, date and utility information is visible and verifiable.

    P.O Boxes do not prove residency.

     


    All applicants, including those who are reapplying, are required to provide eligibility documents, from the items listed above. 

     

     

    Revised 7/7/2025

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