SENIOR IN NEED APPLICATION

SENIOR IN NEED APPLICATION
Please read:

Senior Service Network may award up to $500 to assist with emergent needs. If your needs exceed this amount, we may not be able to assist and will do our best to direct you to other resources that may better suit your needs.

This application may not be considered if required documentation is not included (uploaded) with the application. If you are experiencing difficulty with this, we ask that you seek help. Often, friends, family and trusted neighbors are happy to assist. You can also request help through Nevada Care Connection.

Areas that we serve include Carson City, Douglas County, Lyon County, Washoe County, and Storey County.

Applicants who reside in other territories will be considered on a case-by-case basis and awards granted pending a majority vote of the Board.

Payments will be paid directly to the appropriate vendor, not the applicant.

Mail-In Application or Trouble Uploading Documents:

If you would prefer to mail your application, or are unable to upload the required documents on this form, please complete this online application form and select the print form option at the bottom of this page. The information that you fill in here will print on the form. You are also welcome to print a blank form and fill it out by hand.

Mail application and documentation to:

PO BOX 1126

Carson City, NV 89702
Amount Requested & Due Date
How much are you requesting?
When is this due? (if past due, please enter that date)

MonthDayYear
Date
What is your financial request for?
Select the best category that this payment is for
Have you received a shut-off, or final notice?
Point of Contact Information

Please provide the information for this best point of contact for us to contact to help with this request.
First & Last Name
Relationship to applicant
Phone Number
Email Address
What we need to know

The following questions are intended to provide us with important and necessary information to enable us to determine how we may best help you.
Can you describe your situation?
How will receiving this assistance impact your overall financial situation?
Have you sought assistance from any other organizations or sources for this need?
What else are you doing to address this financial challenge?
Applicant's information
First Name
Last Name
Date of Birth*
Phone number
Email Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many people live with you?
Number of adults who live with you
Monthly Income
Monthly Expenses
E-Mail
example@example.com
Phone Number
Employed
Required documentation

Please upload required documentation.
30-day Bank Statement

Upload a File

Cancelof
Upload the bill, or item for which assistance is requested.

Upload a File

Cancelof
For Board Member Use Only
Should be Empty:

Please read:

Mail-In Application or Trouble Uploading Documents:

Amount Requested & Due Date

Point of Contact Information

What we need to know

Applicant's information

Required documentation