HOME Program Application

HOME Program Application

If you have questions while filling out your application, call the HOME Program at 952-746-4046.
THIS IS NOT THE APPLICATION FOR TECHNOLOGY SERVICES. Please only use this form for chore assistance. To apply for Technology Services, click here.
To quality for the HOME Program you must be 60 or older.
YesNo

Unfortunately you are not eligible for services at this time.

If you have a disability and need assistance, you can call Disability Hub MN at 866-333-2466.

Great! Now let's check if your location is eligible.

If your county/city is not listed, we cannot provide services to you currently. To find services available in your city, please call the Senior Linkage Line at 1-800-333-2433 or minnesotahelp.info.
What county do you live in?*
Our services are available in the following Hennepin County cities:*
Our services are available in the following Wright County cities:*
Our services are available in the following Sherburne County cities:*

To see if you qualify for financial assistance through Title III, please follow these instructions to complete and return the Supportive Services form from the State of Minnesota.
1. Fill in the form in the window below. Click and type in each field to fill them in.

2. Click the download button in the top right corner:

3. Click "With your changes."

4. Save the completed form to your computer.

5. Click the Browse Files button and select the form you just filled out to securely send it to our staff as part of this application.
File Upload

Cancelof
If you are unable to upload the completed form, you may print the form and mail it to our office at:

Senior Community Services
10201 Wayzata Blvd, #335
Minnetonka, MN 55305
YesNoI will send my form by mailPlease contact me to complete the Supportive Services form

Please tell us about your living situation and monthly income.
I live aloneI live with my spouseI live with others
Your individual income per month.*
Please let us know your monthly income so we can establish your eligibility for subsidies and rates for service(s)
PRIVATE PAY: Select the option below if you prefer not to share your income. By doing so, you understand this means you will pay the highest hourly rate for services.
Please include all routine monthly income in your calculations. Income sources include Social Security, pensions, annuities, PERA, IRA, retirement distributions or withdrawals, interest income, dividends, estate or trust, disability, Public Assistance, rental income, home equity funds, salary(ies), self-employment income, and all other income sources that are not a voluntary withdrawal of funds

Additional Person in Household

Please fill out this information for the additional person in your household.
Name*

First NameMiddle InitialLast Name
Date of birth*

MonthDayYear
Date
MaleFemaleOther
Race*
Hispanic/LatinoNot Hispanic/Latino
Main Phone Type*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone Type
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please include all routine monthly income in your calculations. Income sources include Social Security, pensions, annuities, PERA, IRA, retirement distributions or withdrawals, interest income, dividends, estate or trust, disability, Public Assistance, rental income, home equity funds, salary(ies), self-employment income, and all other income sources that are not a voluntary withdrawal of funds
Monthly income*
Veteran and Disability Status
YesNo
YesNo
Please describe:

Use of Information Statements
I understand that the information I am providing on this form is for registration purposes. I certify that the information provided on this form is accurate and complete. I authorize Senior Community Services to verify this information, if necessary, and to provide this form to governmental entities as a condition of funding they provided to this agency. This information will not be released to anyone other than the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose.

Applicant Signature
By typing your full legal name, you are providing a digital signature for this application.*

First NameLast Name
FROM (field for internal SCS use)
Date*

MonthDayYear
Date
Should be Empty:

To quality for the HOME Program you must be 60 or older.