MAPS Request Form

IMPORTANT INFORMATION

Please click here to review the "Grant Guidelines" instructions. If you do not have all the materials available, you may save the form and return later. If there is a required field that does not apply, please use "N/A" to fill in the field. This form may require links and/or PDF copies for some requested items.

REQUIRED!*

By clicking here, I have read the GUIDELINES and understand that requests that do not follow these requirements and are submitted without all required documentation are considered incomplete and will be automatically denied.

2023 Request Deadlines

Applications must be received by the following dates to be considered in that month. Requests received after the deadline will be reviewed the following month.

Request Deadlines (by 6:00p.m.)

Dec. 10 - Jan. 19

Jan. 20 - Feb. 16

Feb. 17 - Mar. 16

Mar. 17 - Apr. 13

Apr. 14 - May 11

May 14 - Jun. 15

Jun. 16 - Jul. 20

Jul. 16 - Aug. 17

Aug. 18 - Sept. 14

Sept. 15 - Oct. 19

Oct. 20 - Nov. 9

Nov. 10 - Dec. 7

>>> Click here for a copy of the Grant Request Timeline with deadline and approval dates <<<

PSA Name*

PSA FirstPSA Last

PSA Title*

PSA Email Address*

example@example.com

Agency Name*

Agency Address*

PSA Street

PSA Street 2 (optional)

PSA CityPSA State

PSA Zip

PSA Phone Number - Work*

Please enter a valid phone number.

PSA Phone Number - Extension (if any)

PSA Phone Number - Cell

Please enter a valid phone number.

Are you a new PSA to MAPS Charities?*

YesNo

Client Name*

Client FirstClient Last

Client Address*

Client Street (INCLUDING APARTMENT NUMBER, IF ANY)

Client Street 2 (optional)

Client CityClient State

Client Zip

Client Phone Number*

Please enter a valid phone number.

Client Date of Birth*

Client must be at least 65 years of age

PROOF OF AGE (required): Please upload a copy of client's identification. Qualified proof is Passport, Drivers License or State Identification Card *

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Client Gender (mark only one)*

FemaleMaleOther

Client Ethnic Origin (mark only one)*

Client Status - Please check all that apply*

Holocaust SurvivorHomelessVeteranN/A

When did you begin working with the client?*

Date

Assessment of Client Needs and Circumstances*

DETAILED SUMMARY OF NEED, please explain the circumstances and needs of the senior client.0/0

Types of Requests - Review GUIDELINES before submitting

>>> Click here to review GUIDELINES <<<

Choose the Type(s) of Request(s)

Purchase of Item(s) - i.e. walker, shower chair, mattress, etc. If item(s) are over $200 each, a minimum of two quotes are required. All quotes must include tax, delivery, assembly, installation and haul away. Link(s) must be provided for online purchases. You will be given the opportunity to submit for more than one item.Payment Request(s) - Payment of an outstanding bill, i.e. utility or dental bill. Required: Payee and address where check should be mailed, account number and a copy of the bill. A W-9 is required for all bills, except for utility bills. You will be given the opportunity to submit more than one bill.Rent Assistance - A lease agreement or letter from the landlord/management company and a W-9 is required. See Guidelines for information needed.Home Care or Adult Day Care Assistance - Copy of caregiver agency business license, W-9 and quote for service provided by agency on letterhead is required.

FIRST Purchase Item

FIRST Item Cost - Include all applicable fees such as tax, delivery, assembly, installation and haul-away charges

FIRST Item Link 1 - Copy Purchase Item link from your browser and paste it here.

FIRST Item Link 2 - If item is over $200, copy/paste second link here.

FIRST Item - Upload your PDF file(s) of estimate(s), if any (must be clear and legible)

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Do you have a second Purchase Item?

YesNo

SECOND Purchase Item

SECOND Item Cost - Include all applicable fees such as tax, delivery, assembly, installation and haul-away charges

SECOND Item Link 1 - Copy Purchase Item link from your browser and paste it here.

SECOND Item Link 2 - If item is over $200, copy/paste second link here.

SECOND Item - Upload your PDF file(s) of estimate(s), if any (must be clear and legible)

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Do you have a third Purchase Item?

YesNo

THIRD Purchase Item

THIRD Item Cost - Include all applicable fees such as tax, delivery, assembly, installation and haul-away charges

THIRD Item Link 1 - Copy Purchase Item link from your browser and paste it here.

THIRD Item Link 2 - If item is over $200, copy/paste second link here.

THIRD Item - Upload your PDF file(s) of estimate(s), if any (must be clear and legible)

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Do you have more than three Purchase Items?

YesNo

If more than three items are requested, include item name, cost, link(s) for purchase. If a single item is over $200, include two links for that item.

Total cost of purchase items (over three) listed above

FIRST Payment Request - Name of Payee (i.e utility or medical company)

FIRST Payment Request - Enter account number (if no account number is available, enter "N/A")

FIRST Payment Request - Cost

FIRST Payment Request - Upload PDF file of Utility Statement or Medical Bill/Estimate (must be clear and legible). A W-9 is required for all bills, except for utility bills.

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Do you have second Payment Request?

YesNo

SECOND Payment Request - Name of Payee (i.e. utility or medical company)

SECOND Payment Request - Enter account number (if no account number is available, enter "N/A")

SECOND Payment Request - Cost

SECOND Payment Request - Upload PDF file of Utility Statement or Medical Bill/Estimate (must be clear and legible). A W-9 is required for all bills, except for utility bills.

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Do you have a third Payment Request?

YesNo

THIRD Payment Request - Name of Payee (i.e. utility or medical company)

THIRD Payment Request - Enter account number (if no account number is available, enter "N/A")

THIRD Payment Request - Cost

THIRD Payment Request - Upload PDF file of Utility Statement or Medical Bill/Estimate (must be clear and legible). A W-9 is required for all bills, except for utility bills.

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Rent Assistance - Amount Requested

Landlord/Management Company

Name of Landlord/Management Company. IF LANDLORD, PLEASE GIVE FIRST AND LAST NAME

Landlord Street Address (Location where check is to be mailed)

Landlord CityLandlord State

Landlord Zip

Email Address of Landlord/Management Company

example@example.com

Lease Agreement or Letter from the Landlord/Management Company - Upload PDF file

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W-9 from the Landlord/Management Company - Upload PDF file

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Home Care or Adult Day Care Agency Name

Home Care or Adult Day Care Assistance - Requested Amount

Upload a PDF of Home Care or Adult Day Care Agency License

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Upload a PDF of Home Care or Adult Day Care Agency Rates on agency letterhead

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Upload a PDF of Home Care or Adult Day Care Agency W-9

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TOTAL Amount of all Requests (IF THE TOTAL EXCEEDS $500, YOU WILL BE UNABLE TO SUBMIT. Total must include tax, shipping, installation and haul-away where applicable.)

PSA Certification/Electronic Signature - You agree your electronic signature is the legal equivalent of your manual signature on this Request.*

I certify that I have verified, to the best of my ability, that the information on this form provided to me by the Client is true and accurate. The above named Client has authorized me to make this request on their behalf. The Client understands that their name will appear on orders, checks and forms for purposes of identification. Without using the Client's name, MAPS Charities may use this information for promotional purposes or for use in telling the MAPS Charities' story.

If you have a question about this submission, please click the "Save" button below and send your question to office@mapscharities.org.

Request For Grant

Professional Senior Advocate (PSA) and Agency Information

Client Information

The following three questions are required for MAPS Charities' funding purposes.

Purchase of Item(s)

Payment Request

Rent Assistance

Home Care or Adult Day Care Assistance