Client Grant Assistance Application

APPLICANT INFORMATION

Full Name *

Date of birth

Phone *

Email *

Address

Street Address *

City

State

Country *

Postal Code

Primary Language_

GUARDIAN / RESPONSIBLE PARTY (If Applicable)

Do you have a responsible party?

Yes

No

Responsible Party Name

Relationship to Applicant

Responsible Party Phone

ELIGIBILITY INFORMATION

FINANCIAL INFORMATION

Total Monthly Household Income *

$

Monthly Housing Expense

$

Do you currently receive Medicaid?

Yes

No

Pending

Do you have Long-Term Care Insurance?

Yes

No

CARE NEEDS ASSESSMENT

Estimated Hours Needed Per Week

Describe Current Challenges & Why Assistance Is Needed *

EMERGENCY STATUS

Is this request urgent?

Yes

No

If urgent, please explain:

REQUIRED DOCUMENTS

Upload Required Documents

Please upload: - Government ID - Proof of Income - Medical Discharge Paperwork (if applicable) - Proof of Residency

CERTIFICATIONS

Certification Agreement *

I certify that the information provided is true and accurate. I understand submission does not guarantee approval and is subject to funding availability."

Digital Signature *

Clear

By checking this box, I consent to receive non-marketing text messages from Comfort Care Senior Care about Joining our team. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others .from Comfort Care Senior Care at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Comfort Care Senior Care is an Equal Opportunity Employer.

All employment is contingent upon background verification and compliance with Alabama state regulations.