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!*

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 <<<
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.
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 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.
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 *

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

FemaleMaleOther
Client Race/Ethnicity Origin (mark only one)*

African American/BlackAsian/East Asian/Pacific IslanderHispanicMultiracialNative American/Alaska NativeWhiteOther
Does your client suffer from any of the following? (select any that apply)

Chronic illnessCognitive impairmentIncontinence issuesMental health issuesMobility impairmentTerminal illness
Client Status - Please check all that apply*

Holocaust SurvivorHousedCurrently unhousedPreviously unhousedAt risk of being unhousedVeteran
What is your client's living situation?*

Lives aloneLives with familyLives with friend(s)Lives with roommate(s)Other
Monthly household income:*
Please enter a number
Sources of monthly income (select all that apply)*

Financial support from familySocial Security (SS)Supplemental Security Income (SSI)Pension/savingsOther
Monthly Rent/Mortgage:*
Please enter a number
Section 8 Voucher:*

YesNo
Enrolled in Calfresh/SNAP:*

YesNoAwaiting enrollment
Enrolled in Medi-Cal:*

YesNoAwaiting enrollment
How did you complete your assessment of the client:*

In client's homeOver the phoneAt agency/senior center locationOther
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)

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 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)

Cancelof
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 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)

Cancelof
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 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)

Cancelof
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*
What does your client choose as their FIRST payment request?*

Utility Bill (gas, electric, water, TV/cable, internet, telephone)Dental, vision, hearing aid, DME installationOther
FIRST Utility: Is your client participating in a Payment Plan for this utility?*

YesNo
FIRST Utility: Is your client enrolled in a Discount Program for this utility?*

YesAwaiting enrollment statusNo
FIRST payment request - Name of Payee*
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*

Cancelof
FIRST payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible). *

Cancelof
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*

YesNo
FIRST payment request: Please give us details on how the remaining balance will be paid:*
Do you have second Payment Request?

YesNo
What does your client choose as their SECOND payment request?*

Utility Bill (gas, electric, water, TV/cable, internet, telephone)Dental, vision, hearing aid, DME installationOther
SECOND Utility: Is your client enrolled in a Discount Program for this utility?*

YesAwaiting enrollment statusNo
SECOND Utility: Is your client participating in a Payment Plan for this utility?*

YesNo
SECOND payment request - Name of Payee*
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*

Cancelof
SECOND payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible).*

Cancelof
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*

YesNo
SECOND payment request: Please give us details on how the remaining balance will be paid:*
Do you have a third Payment Request?

YesNo
What does your client choose as their THIRD payment request?*

Utility Bill (gas, electric, water, TV/cable, internet, telephone)Dental, vision, hearing aid, DME installationOther
THIRD payment request: Is your client enrolled in a Discount Program for this utility?*

YesAwaiting enrollment statusNo
THIRD payment request: Is your client participating in a Payment Plan for this utility?*

YesNo
THIRD payment request - Name of Payee*
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*

Cancelof
THIRD payment request: Upload PDF file of W-9 for DDS, vision center/optometrist or installation company is required (must be clear and legible).*

Cancelof
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*

YesNo
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*

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

Cancelof
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*

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

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

Cancelof
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:
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.
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.