Senior Support Application

Mountain Heart Ministries seeks to help older adults facing difficult circumstances with essential needs, safety concerns, and challenges that can make everyday life harder. Assistance may include food, utilities, transportation, home safety needs, essential household items, or help connecting with available community resources and benefits.

Name *

Phone

Email Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal code *

Date of Birth *

Who is completing this application? *I am completing this application for myselfA family member is helping meA friend or neighbor is helping meA caregiver is helping meA church or community organization is helping meOther

If someone is helping complete this application, please provide their name.

Helper's phone number

Helper's Email Address

What is the current living situation of the person requesting assistance? *Lives aloneLives with spouseLives with family or relativesLives with a caregiverAssisted living or senior housingOther

What type of assistance is being requested? *Food or groceriesUtility assistanceEssential household itemsHome safety or accessibility needsTransportationPrescription or medical-related expensesHeating or cooling needsPersonal care itemsHelp connecting with senior or community servicesOther

Please tell us specifically what assistance is needed and what has happened that caused the need at this time. *Please include any details that will help us understand the situation and the most important need.

What is the approximate total monthly household income of the person requesting assistance? *Include Social Security, SSI/SSDI, retirement or pension income, wages, veterans benefits, or other regular income. Enter numbers only — do not use a dollar sign or commas. Example: Enter 1500 instead of $1,500.

What sources of income or financial assistance does the household currently receive? *Social SecuritySSI/SSDIRetirement/PensionEmployment/WagesVeterans BenefitsSNAP/Food AssistanceHousing AssistanceNo current incomeOther

Does the person requesting assistance have someone who regularly helps with essential needs? *YesSome help, but it is limitedNo

Is the person requesting assistance currently having difficulty paying for any of the following essential needs? *FoodElectricity, water, or other utilitiesHousingPrescription medicationsMedical or dental careHeating or coolingHome repairs needed for safetyPersonal care or household necessitiesTransportationNone of the aboveOther

How soon is this assistance needed? *Immediately — within 24–48 hoursWithin one weekWithin two weeksWithin 30 daysNo specific deadline

What will happen if this assistance is not received? *Please briefly explain how this would affect the person requesting assistance or their household.

Has the person requesting assistance contacted any other organization, church, agency, senior program, or assistance program for help with this need? *YesNoNot sure

If yes, please tell us who was contacted and what assistance was received or offered.Include the name of the organization, church, agency, senior program, or other resource and the outcome of the request.

Are there other needs that would make daily life safer or easier for the person requesting assistance?Help obtaining groceries or mealsHome safety items such as grab bars or railingsHelp obtaining needed mobility equipment or assistanceTransportation to appointments or essential errandsHelp with minor home repairsHeating or cooling needsHelp connecting with available senior or veterans' benefitsRegular contact or companionshipOtherNo additional needs at this time

Does the person requesting assistance have reliable access to enough food and regular meals? *YesUsually, but there are times when food is limitedNoNot sure

Does the person requesting assistance have reliable transportation for medical appointments, groceries, and other essential needs? *YesSometimes/transportation is limitedNoNot sure

Is there anything else you would like Mountain Heart Ministries to know about the person requesting assistance or their situation?Please share any additional information that may help us understand their needs or circumstances.

Who should Mountain Heart Ministries contact regarding this application? *The person requesting assistanceThe person helping complete this applicationEither person

What is the best way for Mountain Heart Ministries to make contact about this application? *Phone callText messageEmail

Verification Authorization *I authorize Mountain Heart Ministries to verify information provided in this application with appropriate individuals, organizations, agencies, service providers, or other sources when necessary to evaluate this request for assistance.

Information Certification *I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that false or misleading information may result in the request being denied.

Assistance Acknowledgment *I understand that submitting this application does not guarantee that Mountain Heart Ministries will provide assistance. Requests are reviewed based on individual circumstances, available resources, and the ministry’s ability to help.

Who is signing and submitting this application? *I am the person requesting assistanceI am helping the person requesting assistance complete this application

Electronic Signature — Please type your full legal name *By typing my name below, I certify that I am the person identified above and that the information I have provided is true to the best of my knowledge.

Date *

Submit Application