Global Blessing, Inc.
2417 Canton Road, Marietta, GA 30066
globalblessinginc@myglobalblessings.com
www.myglobalblessings.com
(470) 813-4339
Emergency Rental Assistance Application
Application Details:
This application is to determine eligibility for the Emergency Rental Assistance Program. For program details, visit our website at www.myglobalblessings.com/our-services. For any additional questions, email info@myglobalblessings.com.
Personal Information
Use this section to provide contact details.
Full Name of individual filling out the form
*
First Name
Last Name
Full Name of individual needing assistance
*
First Name
Last Name
Social Security Number
*
Format: {xxx-xx-xxxx}
Gender
*
Please Select
Male
Female
Non-binary
Transgender Male
Transgender Female
Not Applicable
Other
Relation to individual needing assistance
*
Self
Spouse, Partner
Child
Parent
Social Worker
Friend
Other
If other, please specify
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Phone Number to Contact
*
Best E-mail Address
*
example@example.com
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Details of Senior Needing Assistance
Please fill out this section according to the information of the senior requiring assistance from our program. This information serves to help us determine eligibility for the program and as well provide us with the relevant information needed to tailor our assistance to their needs.
Age Group
*
Less than 55 years old
55-64 years old
65+ years old
Sex
*
Male
Female
Rather not answer
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Prior Occupation
*
Veterans Status
*
Veteran
Spouse/Partner to a Veteran
N/A
Not Sure
Medicaid Qualification
*
Qualify, currently receiving
Qualify, application pending
Qualify, have not applied/need assistance with application
Do not qualify
Not sure
Current Residential Status
*
Homeowner
Leasing/Renting
Living as a dependent with family
Senior living facility/LTC
Homeless/Housing Insecure
Total Monthly Income
*
In $USD
Income Sources
*
Ex: supplemental income, other nonprofit programs, government assistance, etc.
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Care Facility Details
Please fill out the form to let us know which care facility or rental complex the senior in question, if applicable, would be moving into within the next 30 days.
Name of Care Facility or Rental Complex
Type of Housing
Nursing Home
Assisted Living
Personal Care Home
Rental Complex
Other
If other, please specify
Address of Care Facility or Rental Complex
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Monthly Rate at Care Facility or Rental Complex
Phone Number of Care Facility or Rental Complex
Please enter a valid phone number.
Full Name of Point of Contact at the Care Facility or Rental Complex
First Name
Last Name
Title of Point of Contact
E-mail Address
example@example.com
Website, if applicable
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Additional Comments
How did you hear about us?
*
Please Select
Newspaper
Google/Internet
Social Media
Website
Friend/Family Referral
Event
Other
Please Specify
Please use the space below to describe the current financial emergency situation:
Submit
Should be Empty: