We Deliver Quality of Life

* Required fields

County:

—Please choose an option—Anne Arundel CountyBaltimore CityBaltimore CountyCarroll CountyFrederick CountyHarford CountyHoward CountyMontgomery CountyPrince George's County

Birth date: (XX/XX/XXXX)

Race:

—Please choose an option—American Indian or Alaska NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or Pacific islanderWhiteRace Missing

Ethnicity: —Please choose an option—Hispanic or LatinoNot Hispanic or LatinoEthnicity Missing

How did you hear about Meals on Wheels of Central Maryland? *
(hold CTRL/Command to select multiple)

Meals on Wheels EventMeals on Wheels FlyerWord of MouthPrint Publication/AdInternet SearchSocial MediaOther (please specify)

Who should we contact regarding the application? (Please include name and phone number) *

Emergency Contact:

What Program are you applying for? *

Home Delivered MealsGrocery Shopping AssistanceMy Groceries To-Go!(ONLY Available to residents 60 & older residing in Baltimore City)

Reason for needing assistance: *

I am homebound *

NoYes

I am unable to shop or cook for myself *

NoYes

Have you ever served in the military? *

NoYes

Has your spouse ever served in the military? *

NoYes

Health, mobility or dietary concerns we should be aware of:

Special dietary needs for delivered meals:

NoYes

When would you like to begin service? (Please allow 3 business days)

Enter date: (XX/XX/XXXX)

Days Requested: * (hold CTRL/Command to select multiple)

MondayTuesdayWednesdayThursdayFridayWeekend

Is this anticipated to be a temporary need following surgery, etc.?

NoYes

Do you have a social worker or case manager assisting you from another agency?

NoYes

Social Worker Info:

MONTHLY INCOME (Include all sources): *

Please note: This information helps us determine a manageable fee based on your income and expenses. Please be prepared to provide your MONTHLY income and MONTHLY expenses during the scheduled telephone intake. Although documentation is not required, it is important that you report both your full income and all your expenses accurately. Failure to report all sources of income may result in an inability to initiate services.

Please be prepared with the following information for our follow up call:

• BGE

• Personal Medical Care: In-Home aides, ensure/boost, depends etc.

• Housing: Rent or Mortgage

• Rx/prescriptions cost

• Oil: heating (winter months)

• Medical/Doctor: Co-pays

• Telephone/Cable

• Transportation

• Taxes: Property, Outstanding IRS (Please specify)

• Water

• Insurance: Medical (out of pocket), Renters, Life or Homeowners (Please specify)

Name and phone number of Person Completing application:

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;

2. fax: (833) 256-1665 or (202) 690-7442

3. email: program.intake@usda.gov.

This institution is an equal opportunity provider.

02/06/2020

Thank you for submitting your application. Someone from our office will contact you within 3 business days to schedule your telephone intake.