Application...
 

Please do not apply at this time.  We are currently searching for new sponsors!

The application process
You must request an application by sending your name and address via e-mail or via postal service. You may also download and application from this website. All information received on submitted applications is strictly confidential and your name is not shared with any other agency.

Our application for assistance in part consists of the following:

• Personal information about yourself

• A signed doctor’s statement

• Narrative concerning your request

• A recent photo of yourself

• Copy of your current Medicaid card

• Proof you are receiving Supplemental Security Income (SSI) and/or Social Security Disability Income (SSDI)

• Copy of your Social Security card or statement from your Social Security office showing your full name and Social Security number

NOTE: All information received with your application will be verified. Please do not submit an application for assistance unless you meet our guidelines.  Click here for a list of our guidelines.

IMPORTANT:  Do not send any application materials via email.  For security purposes, we ask that you send your application via postal mail.  Click here for our address and contact information.

Download application as an Adobe Reader PDF file
Download application as an RTF file

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