New MAPS Request Form

MAPS Charities is a nonprofit charitable, tax-exempt organization dedicated to assisting seniors in need. 501(c)(3) #27-0749461
Request For Grant
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!
2026 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. 5 - Jan. 8

Jan. 9 - Feb. 5

Feb. 6 - Mar. 12

Mar. 13 - Apr. 16

Apr. 17 - May 21

May 22 - Jun. 18

Jun. 19 - Jul. 23

Jul. 24 - Aug. 20

Aug. 21 - Sep. 17

Sep. 18 - Oct. 15

Oct. 16 - Nov. 12

Nov. 13 - Dec. 3

>>> Click here for a copy of the Grant Request Timeline with deadline and approval dates <<<
Professional Senior Advocate (PSA) and Agency Information
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.Format: (000) 000-0000.
PSA Phone Number - Extension (if any)
PSA Phone Number - Cell
Please enter a valid phone number.Format: (000) 000-0000.
Are you a new PSA to MAPS Charities?
Client Information
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.Format: (000) 000-0000.
Client Date of Birth

MonthDayYear
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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The following questions are required for MAPS Charities' funding purposes.
Client Gender (mark only one)

Other
Client Race/Ethnicity Origin (mark only one)

Other
Religious Affiliation:
Does your client suffer from any of the following? (select any that apply)
Client Status - Please check all that apply
What is your client's living situation?

Other
Monthly household income:
Include all sources of monthly income (see following question)
Sources of monthly income (select all that apply)

Other
Monthly Rent/Mortgage:
Please enter a number
Section 8 Voucher:
Enrolled in Calfresh/SNAP:
Enrolled in Medi-Cal:
How did you complete your assessment of the client:

Other
When did you begin working with the client?

MonthDayYear
Date
Why at this time does your client need assistance? What in their situation has changed?
Is there anything else you would like us to know about your client's situation?
Types of Requests - Review GUIDELINES before submitting

>>> Click here to review GUIDELINES <<<
Choose the Type(s) of Request(s)
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 and paste link to the individual item - not the shopping cart
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?
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 and paste link to the individual item - not the shopping cart
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?
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 and paste link to the individual item - not the shopping cart
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?
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
What does your client choose as their FIRST payment request?

Other
FIRST Utility: Is your client participating in a Payment Plan for this utility?
FIRST Utility: Is your client enrolled in a Discount Program for this utility?
FIRST payment request - Name of Vendor
FIRST payment - Account/Reference number (if none, enter "N/A")
FIRST payment request - Amount requested
FIRST payment request - Total amount owed
FIRST payment request: Upload PDF file of bill or estimates

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FIRST payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible). ONLY COMPLETED W-9 FORMS ARE TO UPLOADED HERE.

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FIRST payment request: I have confirmed that the practitioner will set up a payment plan and/or begin treatment once the MAPS Charities' payment is received
FIRST payment request: Please give us details on how the remaining balance will be paid:
Do you have second Payment Request?
What does your client choose as their SECOND payment request?

Other
SECOND Utility: Is your client enrolled in a Discount Program for this utility?
SECOND Utility: Is your client participating in a Payment Plan for this utility?
SECOND payment request - Name of Vendor
SECOND payment - Account/ reference number (if none, enter "N/A")
SECOND payment request - Amount requested
SECOND payment request - Total amount owed
SECOND payment request: Upload PDF file of bill or estimates

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SECOND payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible). ONLY COMPLETED W-9 FORMS ARE TO UPLOADED HERE.

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SECOND payment request: I have confirmed that the practitioner will set up a payment plan and/or begin treatment once the MAPS Charities' payment is received
SECOND payment request: Please give us details on how the remaining balance will be paid:
Do you have a third Payment Request?
What does your client choose as their THIRD payment request?

Other
THIRD payment request: Is your client enrolled in a Discount Program for this utility?
THIRD payment request: Is your client participating in a Payment Plan for this utility?
THIRD payment request - Name of Vendor
THIRD payment - Account/Reference number (if none, enter "N/A")
THIRD payment request - Amount requested
THIRD payment request - Total amount owed
THIRD payment request: Upload PDF file of bill or estimates

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THIRD payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible). ONLY COMPLETED W-9 FORMS ARE TO UPLOADED HERE.

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THIRD payment request: I have confirmed that the practitioner will set up a payment plan and/or begin treatment once the MAPS Charities' payment is received
THIRD payment request: Please give us details on how the remaining balance will be paid:
Rent Assistance - Amount Requested
Total rent owed
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. THIS IS REQUIRED. Do not upload any documents here other than a COMPLETED W-9.

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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. ONLY COMPLETED W-9 FORMS ARE TO UPLOADED HERE.

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IF THE TOTAL EXCEEDS $500, YOU WILL BE UNABLE TO SUBMIT. Total must include tax, shipping, installation and haul-away where applicable. Total Amount of Requests:
Verified Information
Third-Party Sharing
PSA Certification/Electronic Signature
If you have a question about this submission, please click the "Save" button below and send your question to office@mapscharities.org.
Should be Empty:

Request For Grant

Professional Senior Advocate (PSA) and Agency Information

Client Information

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