Essential Needs Fund Application

Applicant's Name*
Date of Birth*
MM slash DD slash YYYY
Complete Address (with City, State & ZIP)*
Telephone Number
Number of People in Household*
Number of People under 18 Years Age*
List all individuals living in your household, relationship and date of birth for each:*
Township or City/Village*
Emergency Contact Name, Address & Phone Number*
Are you a veteran, spouse of a veteran or a surviving spouse of a veteran?*
- Yes
- No
If yes, please describe
Are you currently covered by Medicare?
- Yes
- No
Are you currently covered by Medicaid?*
- Yes
- No
Other insurance provider
Medical/dental/vision/and/or prescription
Are you a client of Department of Human Services (DHS)?*
- Yes
- No
If yes, provide DHS Case Worker Name & DHS Case Number
Release of Liability: The Benzie Senior Resources may provide payment only for the above services, items or repairs. I agree that neither Benzie Senior Resources, or any of their officers, employees, agents or servants is in any way responsible for hiring, purchasing or supplying contractors, repair persons, materials or services. I understand and agree to hold harmless Benzie Senior Resources and any of its officers, employees, agents and servants from any and all claims, including but not limited to claims of negligence, breach of contract, defective materials or workmanship obtained by payments received by service or product providers.
Enter your initials if you agree to the Release of Liability*
I understand that failure to provide the information requested on this application may result in a denial of my application. I understand that a Benzie Senior Resources representative may call my home and/or may contact other individuals to verify my eligibility for assistance. I authorize my utility company to release by telephone, fax, email or website all necessary available information about my account.
Enter your initials if you understand the above*
To the best of my knowledge, the facts presented in this application are true and complete.
Enter your full name to indicate that information provided is true and correct.*

LET’S DO THIS TOGETHER.