Aging Grants Application
Revised March 4, 2026
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.
To be eligible for a grant, you must have less than 6 months of expenses in liquid assets.
(
E.g. if my monthly expenses are $10,000, then I am eligible to apply if my total liquid assets are $60,000 or less
.)
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.
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
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
Do you live alone?
Please select...
Yes
No
With whom do you live? (Select all that apply)
Please select...
With a spouse/partner
With a tenant
With family
With a caregiver
A Roommate
Alone
Do you own your home?
Yes
No
Do you pay a mortgage?
Yes
No
Do you pay rent?
Yes
No
What is the approximate value of your home?
Request Information
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 Income (Social Security Benefits)
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Pension
Annuities
Trust Income
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 (Please round to the nearest whole number, e.g., 1652. Do not include commas or other punctuation.)
Employment Income
Self-Employment Income
Social Security
Pension
Annuities
Trust Income
Is the applicant the sole beneficiary of the trust?
What is the duration of the trust?
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 Monthly Income
Did you file taxes last year?
Yes
No
Total Income from most recent tax return
Do you receive any annual gifts from family or others?
Yes
No
How much did you receive last year in annual gifts from family or others?
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
None
Liquid Assets (Please round to the nearest whole number, e.g. 1652. Do not include punctuation marks such as commas or periods.)
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
Total Liquid Assets
Would you like to clarify anything about your assets?
What monthly expenses do you have? (check all that apply)
Rent
Residence Fee (monthly)
Mortgage payment
RE Tax
Homeowner's Insurance
Renter's Insurance
Home security system fee (monthly)
Food
Utilities
Clothing and personal expenses
Phone, cable, & internet expenses
Medical expenses
Medical insurance
Long-term care insurance
Car Insurance
Caregiver fees
Car payment or public transit expenses
Pet-related expenses
Federal Taxes (estimated monthly)
State taxes (estimated monthly)
Local taxes (estimated monthly)
Applicant's Monthly Expenses (Please round to the nearest whole number. e.g. 1652. Do not include punctuation marks such as commas or periods.)
Monthly Residence Fee
How much is your monthly mortgage payment?
Include property taxes and insurance, if applicable.
How much is your monthly rent?
How much is your monthly RE Tax?
How much is your monthly Home Owner's Insurance?
How much is your monthly Renter's Insurance?
How much does your security system cost monthly?
Food
Utilities
Gas, Electric, Water
Clothing/Personal Expenses
Phone, Cable, Internet Expenses
Medical Expenses
(Co-pays, supplies, medicine)
Medical Insurance
Long-term Care Insurance
Auto Insurance
How much do you personally pay your care giver? (Monthly)
Car Payment or Public Transit Expense
Please include car payments, gas, tolls, and other monthly expenses.
Monthly Pet-Related Expenses
Monthly Estimated Federal Taxes
Monthly Estimated State Taxes
Monthly Estimated Local Taxes
Total Monthly Expenses
Ongoing Debt
Do you owe medical debt?
Yes
No
What is the total balance of your medical debt?
Do you have credit card debt?
Yes
No
How much credit card debt do you owe?
What is your monthly minimum credit card payment?
Would you like to clarify anything about your expenses?
Documentation
Most Recent Checking Account Statement
Most Recent IRA Statement
Most Recent Savings Account Statement
Most Recent Money Market Account Statement
Most Recent CD Account Statement
Most Recent Stock, Bond, or Mutual Fund Statement
Most Recent Other Asset Statement
Most Recent IRS Tax Return
Additional File (if necessary)
Additional File (if necessary)
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?