The Blue Card – 2025 Recertification Form for Existing Clients

The Blue Card – 2025 Recertification Form for Existing Clients
General Information

Please fill out this section completely.
Applicant Full Name*

First NameLast Name
Previous Name/Maiden Name*
Last Four Digits of Social Security Number*
Date of Birth*

DayMonthYear
City, Country of Birth*
Spouse's Full Name*

Spouse First NameSpouse Last Name
Last Four Digits of Social Security Number*
Spouse's Date of Birth*

DayMonthYear
City, Country of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
General Financial Information

Please Include All Monthly Household Income
Monthly SSA/SSI/SSD:*
Pension from other countries:*
Other Pensions/IRA:*
Other Income, including funds from agency and family:*
SNAP Benefits:*
Please select all that apply:*

MedicarePart DMedicaidEpicOther
Total of all bank accounts and investments:*
General Financial Information

Please Include All Monthly Household Expenses
Health Insurance/Life Insurance:*
Gas/Electric/Phone/ Cable*
Medical/RX:*
Food:*
Monthly Payments (Debt):*
Rent/Mortgage (after Sect 8 or SCRIE):*
Other (Please Explain):
Did you file taxes?*

YesNoOther
Financial Aid Recommendation (If Applicable):

In the space below, kindly provide your recommendation on ways you believe The Blue Card can best serve your client.
Blue Card program recommendation

Telephone Emergency Response program (TERS)HolidayMazel Tov BirthdayMonthly stipendSiggi B. Wilzig Fighting Cancer Together ProgramMark Cuban's Cost Plus Drug ProgramFreestyle Libre 2Robotic Companion Pet
Emergency Assistance Programs Recommendation

DentalHearing aidesRent assistanceFood assistanceUtilities assistanceTransportationHome modification (railings, stair lift, home damage, applicance repair)Winter coatMedication or medical expense
Case Worker Recommendation:
Signatures
I affirm that the information in this for is true and accurate according to my knowledge.
Case Worker Signature:*
Case Worker Email Address:*
Case Worker Telephone Number:*
Date*

DayMonthYear
Holocaust Survivor Consent*
Please upload all relevant supporting documentation for the request, including three months' most recent bank statements, most recent SSI award letter, current lease, and any invoices or bills relating to the request.

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The Blue Card – 2025 Recertification Form for Existing Clients

General Information

General Financial Information

General Financial Information

Financial Aid Recommendation (If Applicable):

Signatures