ADRC Application 2025 Forms

ADRC Application 2025 Forms

The Aging and Disability Resource Center (ADRC) connects older adults, individuals with disabilities, and their caregivers to vital resources and services. Whether you’re seeking assistance with housing, healthcare, or long-term care planning, ADRC is here to help. Please fill out this form with your detailed personal information to receive support.
Full Name*

First NameLast Name
Email Address*
example@example.com
Mother Maiden Name

Street Address Line 2

CityState / Province

Postal / Zip Code
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.

what currently described your employment status?*
What was your gross annual income in 2023

Street Address Line 2

CityState / Province

Postal / Zip Code
What was your household's income in 2023

Your household annual income is the total of what everyone in your household over age 18 earned in 2023. Total should include: Wages, Salaries, Unemployment benefits, Pensions, Supplemental Security Income (SSI), Rental income

Street Address Line 2

CityState / Province

Postal / Zip Code
How many people live in your household including you?

Everyone living in your home including you.

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you Disabled?

Do you have any disabilities or medical conditions that may impact your ability to access or maintain stable housing?

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you received a past due rent, eviction notice, or other official notice?

Any notice that may help to get you approved

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any utility bill that shows your name and rental address?

This document would be used for further verification upon approving your rental assistance.

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have documents that show your past rent payments?

This might include receipts, bank statements, check stubs, screenshots of electronic payments, or other types of documentation.

Street Address Line 2

CityState / Province

Postal / Zip Code
I attest that this information provided for household income is correct and complete to the best of my knowledge.

Did you receive assistance from a state or federal program to cover rent during the months for which you are requesting ERA assistance?*
Did you file tax return last year or in recent years?*
Which financial institution do you bank with?

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*

Street Address Line 2

CityState / Province

Postal / Zip Code
Government-issued ID*
Identity card front

Cancelof
Identity card back

Cancelof
Please upload a clear picture of a valid government-issued ID for identification purposes. Ensure that the uploaded document is your driver's license, and not any other form of identification. This will help us verify your identity accurately. Thank you.
Do you have an Id.me account?*
ID.me would be used for further personal verification upon arriving your relief assistance.
How did you hear about us?*
NOTE: For confirmation of participation in any federal, state, or local government assistance program does not negatively impact your eligibility but instead may expedite your application.
I attest that this information provided for household income is correct and complete to the best of my knowledge.
Should be Empty: