Grant Provider* --None-- Elderhouse Inc Fairfield County House Inc Family and Childrens Agency Hall Senior Center Home Together Jewish Senior Services Town of Monroe Town of Trumbull Westport Center for Senior Activities SWCAA Grant Name* Care Recipient Recipient First Name* Recipient Last Name* Recipient Gender* Female Male Non-Binary Other Recipient Marital Status* Married Widowed Divorced Separated Single Recipient Primary Language* English Spanish Italian Polish French Chinese Creole Russian German Greek Hindi Vietnamese Urdu Albanian Korean Arabic Gujarati Kru, Ibo, Yoruba Telegu Serbo-Croatian Bengali Ukrainian Japanese Mandarin Hungarian Tamil Turkish Patois American Sign Language Other Danish Cantonese Romanian Farsi Cambodian Portuguese Tactical Sign Language Recipient English Proficiency* Proficient English Some English Limited English No English Recipient Date of Birth (MM/DD/YYYY) * Recipient Phone* Recipient Street* Recipient City* Recipient State/Province* Recipient Zip* Recipient Has Alzheimer’s Disease or a Related Dementia Recipient Ethnicity* --None-- Hispanic/Latino Not Hispanic/Latino Recipient Race (select all that apply)* White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Recipient Individual Income is About: --None-- Under $1073 (100%) $1074-$1342 (125%) $1343-$1610 (150%) $1611-$1878 (175%) $1879-$2147 (200%) $2148 or over (over 200%) Recipient Lives With Their Spouse and Both of Their Income Is About: --None-- Under $1452 (100%)) $1453-$1815 (125%) $1816-$2178 (150%) $2179-$2540 (175%)) $2541-$2903 (200%) $2904 or over (over 200%) Recipient Living Arrangements* --None-- Alone With Spouse With Unmarried Partner With Spouse/Partner and Child/Children With Child, No Spouse With Grandchildren With Other Relatives With Others Recipient Housing* --None-- Private Home Private Apartment Senior Housing Congregate Housing Public Housing Nursing Home Residential Care Home Assisted Living Other Recipient Needs Help With the Following Activities (select all that apply) Eating Dressing Bathing/Washing Using Toilet Getting Out of Bed/Chair Continence Recipient Needs Help With the Following Activities (select all that apply) Planning/Preparing Meals Shopping Managing Money Using Telephone Housekeeping Doing Laundry Taking Medicine Using Transportation Caregiver Caregiver First Name* Caregiver Last Name* Caregiver Gender Female Male Non-Binary Other Caregiver Relationship* Brother Daughter Daughter-in-Law Domestic Partner Father Husband Granddaughter Grandson Mother Non Relative Other Relative Sister Son Son-in-Law Wife Caregiver Date of Birth* Caregiver Ethnicity* --None-- Hispanic/Latino Not Hispanic/Latino Caregiver Race (select all that apply)* White Black/African American Asian Native American/Alaskan Native Native Hawaiian/Pacific Islander Other Caregiver Phone Caregiver Address Same As Care Recipient? Caregiver Address (Only if addresses do not match) Confirm Form 5 Provider & Grant Name* Additional Comments
