Golden Resource Connections Program
This questionnaire is designed to assess eligibility for the Golden Resource Connections Program, providing seniors aged 55 and older with assistance for utilities, insurance benefits, financial empowerment tools, and legacy kits.
*A copy of the most recent utility bill or shut-off notice is required to submit this application.*
1. Name
*
First Name
Last Name
2. Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
3. Phone Number
*
Please enter a valid phone number.
4. Email
*
example@example.com
5. Are you a resident of Pinellas County?
*
Yes
No
6. Do you have overdue utility bills or need immediate assistance? (Electricity, Gas, Water)
*
Yes
No
7. Are you the primary utility account holder? (Electricity, Gas, Water)
*
Yes
No
8. What is your total ANNUAL household income?
*
Under $22,590
$22,591 to $30,660
$30,661 to $38,730
$38,731 to $46,800
$46,801 to $54,870
$54,871 to $62,940
$62,941 to $71,010
Over $71,011
9. What is your household size? (Number of ALL persons residing at your address).
*
1
2
3
4
5
6
7+
10. Are you currently enrolled in a health insurance program? (Medicare, Medicaid, Humana Gold Plus, etc.)
*
Yes
No
12. Would you like a legacy kit to document important personal and family information? (Financial Power of Attorney, Last Will & Testament, Medical Power of Attorney, Medical Directive)
*
Yes
No
Are you interested in a workshop that teaches you how to stay organized to avoid scams, spot common fraud schemes targeting older adults, and take action if you or a loved one is affected by identity theft?
*
Yes
No
14. How did you hear about the Golden Resource Connections Program?
*
Please upload your most recent utility bill or shut-off notice (dated within the last 30 days).
*
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