Aging Grants Application
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Friends 60 years or older in financial need may apply for grants to assist with basic needs or to make it possible to live in communities, or to remain in their own homes.
Your data is exclusively used for your aging grant application. It will not be shared.
If questions arise while completing this application, please contact Sheila Sorkin, Aging Support Coordinator, at ssorkin@pym.org or grants@pym.org.
Have you received support from Aging Assistance or Greenleaf Granting Groups before?
Yes
No
Are you applying for yourself or someone else?
Myself
Someone else
Who is completing this form?
What is your relationship to the applicant?
Submitter Contact Information
First Name
Last Name
Phone
Email
Mailing Street
Unit/Apartment Number
City, State
Zip Code
Applicant Information
First Name
Last Name
Date of Birth
Meeting Affiliation
Email
Residence Mailing Address
Mailing Street
Unit/Apartment Number
City, State
Zip Code
Has the applicant moved in the past 12 months?
Yes
No
Residence Information
Residential Status
Please select...
A Quaker Retirement Community
A Non-Quaker Retirement Community
My Own Home
A Rental Property
Someone Else's Home
Name of Community
Community Contract Type
Life Care
Fee for Service
Monthly Fee
Do you live alone?
Please select...
Yes
No
With whom do you live?
Please select...
With a spouse/partner
With a tenant
With family
With a caregiver
Alone
Do you own your home?
Yes
No
Do you pay a mortgage?
Yes
No
Do you pay rent?
Yes
No
How much is your monthly mortgage payment?
Include property taxes and insurance, if applicable.
What is the approximate value of your home?
How much is your monthly rent?
Request Information
Is this a one-time or monthly grant request?
One-time
Monthly
Both
Requested One-Time Amount:
Is this one-time request for reimbursement or for an expected future expense?
Reimbursement for Past Expense
Grant for Anticipated Expense
Please upload the receipt.
Please upload the estimate, quote, or invoice.
If approved, please submit a receipt to grants@pym.org when funds are spent.
Requested Monthly Amount:
Please describe how the funds will be used:
If you have a written statement you would like to upload, please do so here
Is your clerk or clerk of care committee aware of your application?
Yes
No
Please have your clerk email grants@pym.org to acknowledge your application.
Please select the types of income you receive (select all that apply).
Employment Income
Self-Employed Income
Social Security
Pension
Annuities
Trust Income
SSI/SSDI
Veteran Benefit
Food Benefit
SNAP
LiHEAP
Medicaid Benefit
PAAD Benefit
Other Benefit
Monthly Gifts from Family or Other Individuals
Monthly Gifts from your Monthly/Quarterly Meeting
Monthly Gifts from other Organizations
Applicant's Monthly Income
Employment Income
Self-Employment Income
Social Security
Pension
Annuities
Trust Income
SSI/SSDI
Veteran Benefit
Food Card Benefit
SNAP Benefit
LiHEAP Benefit
Medicaid Benefit
PAAD Benefit
Other Benefit
Gifts from Family Members or Others
Gifts from Your Monthly or Quarterly Meeting
Gifts from Other Organizations
Total Income from most recent tax return
Would you like to clarify anything about your income?
Please select the types of assets you own (select all that apply).
Checking Account
Savings Account
IRA or other Retirement Account
Money Market Account
CDs
Stocks, Bonds, or Mutual Funds
Other
Liquid Assets
Current Checking Account Balance
Current value of Savings Account(s)?
Current value of IRA or Retirement Account(s)
Current value of Money Market Account(s)
Current value of CD(s)
Current value of Stocks, Bonds, and Mutual Funds
If you selected "other", please specify the type and value of the asset
Would you like to clarify anything about your assets?
Applicant's Monthly Expenses
Food
Utilities
Gas, Electric, Water
Clothing/Personal Expenses
Phone, Cable, Internet Expenses
Medical Expenses
(Co-pays, supplies, insurance, medicine)
Do you owe medical debt?
Yes
No
What is the total balance of your medical debt?
Do you have a paid care-giver?
Yes
No
How much do you personally pay your care giver? (Monthly)
Do you have credit card debt?
Yes
No
How much credit card debt do you owe?
What is your monthly minimum credit card payment?
Car Payment or Public Transit Expense
Do you have a pet?
Yes
No
Monthly Pet-Related Expenses
Would you like to clarify anything about your expenses?
Documentation
IRS Tax Return
For First-Time Applicants
Most Recent Bank Statement
Additional File (if necessary)
Care Coordinator
Do you have a care coordinator from a social service organization?
Yes
No
Care Coordinator Name
Care Coordinator Phone Number
Care Coordinator Email
Financial Power of Attorney
Do you have a financial POA?
Yes
No
Please upload your financial POA.
Financial POA Name
Financial POA Phone Number
Financial POA Email
I understand that establishing a financial power of attorney is required within one year of receiving a grant to remain eligible for future funding
Yes
No
If you did not upload your financial POA, please send a copy to grants@pym.org when complete.
Is there anything else you would like to share?
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