Grant

Provider  *	--None-- Fairfield County House Inc Hall Senior Center Town of Monroe Town of Trumbull SWCAA
Grant Name  *

Care Recipient

Recipient First Name  *
Recipient Last Name  *
Recipient Gender  *	--None-- Female Male Non-Binary Other
Recipient Marital Status  *	--None-- Married Widowed Divorced Separated Single
Recipient Primary Language  *	--None-- English Spanish Italian Polish French Chinese Creole Russian German Greek Hindi Vietnamese Urdu Albanian Korean Arabic Gujarathi 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  *	--None-- 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 *	--None-- White Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander
Recipient Individual Income is About:	--None-- Under $1,255 (100%) $1,256 - $1,569 (125%) $1,570 - $1,883 (150%) $1,884 - $2,196 (175%) $2,197 - $2,510 (200%) $2,511 or over (over 200%)
Recipient Lives With Their Spouse and Both of Their Income Is About:	--None-- Under $1,703 (100%) $1,704 - $2,129 (125%) $2,130 - $2,555 (150%) $2,556 - $2,981 (175%) $2,982 - $3,407 (200%) $3,408 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	--None-- Female Male Non-Binary Other
Caregiver Relationship  *	--None-- 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  *	--None-- White Black/African American Asian American Indian/Native Alaskan Native Hawaiian/Other Pacific Islander
Caregiver Phone (###-###-####) *
Caregiver Address Same As Care Recipient?
Caregiver Address (Only if addresses do not match)

Confirm Form 5

Provider & Grant Name  *
Additional Comments