Global Blessing, Inc.
2417 Canton Road, Marietta, Ga 30066
globalblessinginc@myglobalblessings.com
www.myglobalbelssings.com
(470) 813-4339
Seniors at Home Utility Assistance Application
APplication details:
This application is to determine eligibility for the Seniors at Home Utility Assistance Program. For program details, visit out 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 senior receiving 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
Age Group of senior
*
Less than 55 years old
55-64 years old
65+ years old
Relation to senior receiving assistance
*
Self
Spouse, Partner
Child
Parent
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
*
example@example.com
Total Monthly Income
*
In $USD
Other Income Sources
*
Ex: supplemental income, other nonprofit programs, government assistance, etc.
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Utility Details
Please fill out this section by detailing the utility in which assistance is needed.
Type of Utility
*
Water bill
Heating/Cooling
Electricity/Gas
Trash/Recycling
Landline phone
Internet/Cable
Utility Amount
*
In $USD
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Documents
Please attach a digital copy of the utility bill in question. If applying as an informal caregiver to a senior, please attach additional documentation proving responsibility over senior and that they reside with you. Acceptable documents may include but are not limited to: Power of Attorney Form, Tax Form showing claim of elderly individual as a dependent, Witness Testimony (must be someone other than a family member).
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Additional Comments
How did you hear about us?
*
Please Select
Newspaper
Internet
Magazine
Radio Station
Word of Mouth
Social Worker
Event
Social Media
Other
Please Specify
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