Senior Application Form

Senior Assistance

60 and OVER ONLY
Please note that all required documents may be uploaded by taking a picture with your phone. Please be sure that the document can be read clearly.
Date

MonthDayYear
Name

First NameLast Name
Upload photo of State ID

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Please be sure that numbers are readable. Cancelof
Birthdate

MonthDayYear
Gender

Other
Phone Number

Area CodePhone Number
Email
example@example.com
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Insurance
Choose the option that best represents you.
Head of Household Veteran?
How Many in Household?
Housing
Choose the option that best represents you.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am requesting assistance for the following:

Other
2nd Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
3rd Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
4th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
5th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
6th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
7th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
8th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
9th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
10th Member of Household
Name

First NameLast Name
Relationship to Head of Household
Choose the option that best represents you.
Birthdate

MonthDayYear
Is this person over 18?
Gender

Other
Education
Choose the option that best represents you.
Disabled?
Race
Choose the option that best represents you.
Ethnicity
Employment
Choose the option that best represents you.
Health Insurance
Choose the option that best represents you.
Veteran?
Head of Household Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

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2nd Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
3rd Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
4th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
5th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
6th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
7th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
8th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
9th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
10th Member Income Information
I have Income to Report
Income Total by Employment
Enter Zero if No Income
Pay Period
Enter Monthly if No Income
Income Total by Benefits
Enter Zero if No Benefits received.
Choose Types of Benefits Received

Other
Other Income Total
Enter Zero if No Other Income received.
Choose Types of Other Income Received

Other
Income Document Upload

Browse Files

Cancelof
Assistance
Name of Person or Company to issue Check and account number
Phone Number

Area CodePhone Number
Address to Mail Check

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date Due

MonthDayYear
Date
Amount Due
Upload Bill and ALL IMPORTANT DOCUMENTS: FAILURE to do sure and result in rejected or delay.

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Please make sure that names and/or signatures are readable Cancelof
Signature Page
By signing this Application, I agree to allow BMORE IMPACTFUL HELP to share this application with the purpose of obtaining resources on my behalf. I understand that if elected it is a possiblity that my full bill will not be covered and I am the responsible party.
Head of Household Signature
Self Declaration for Head of Household
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 2nd Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 3rd Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjury that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 4th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 5th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 6th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 7th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 8th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 9th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
Self Declaration for 10th Household Member
Self-Declaration for Zero Income or missing required documentation

(Only complete if you have no source of income or are missing any of the required documentation.)

I do hereby declare under penatly of purjery that I have received no income from any source during the past 30 days and that I have been unemployed during that time.
I have been able to maintain my basic necessities by doing the following:
Signature
How will this help?
Please verify that you are human
Should be Empty:

Senior Assistance

2nd Member of Household

3rd Member of Household

4th Member of Household

5th Member of Household

6th Member of Household

7th Member of Household

8th Member of Household

9th Member of Household

10th Member of Household

Head of Household Income Information

2nd Member Income Information

3rd Member Income Information

4th Member Income Information

5th Member Income Information

6th Member Income Information

7th Member Income Information

8th Member Income Information

9th Member Income Information

10th Member Income Information

Assistance

Signature Page

Self Declaration for Head of Household

Self Declaration for 2nd Household Member

Self Declaration for 3rd Household Member

Self Declaration for 4th Household Member

Self Declaration for 5th Household Member

Self Declaration for 6th Household Member

Self Declaration for 7th Household Member

Self Declaration for 8th Household Member

Self Declaration for 9th Household Member

Self Declaration for 10th Household Member