Basic Needs Request Form (Online Version)

Form
Proudly Assisting The Seniors (PATS)
Basic Needs Request Form

If you are a Detroit senior (age 60+) who is experiencing financial hardships and unable to meet your basic daily needs (food, housing, utilities, medicine, clothing, etc.), you’re eligible to complete this form
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

State/ Zip
Home Phone *
Please enter a valid phone number.
Cell Phone *
Please enter a valid phone number.
Email Address *
[email protected]

	$
Work
Social Security
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Pension or Retirement
Unemployment/Worker’s Compensation
Veterans Benefits (VA)
other

List Current Monthly Expenses:

Are you current on ALL major expenses? *

Yes No
Does anyone in your household have a vehicle (car/truck)? *

Yes No
List make, model, and year: specify
Are there members of the household with a disability? *

Yes No
If yes please specifyspecify .
Please allow 5-7 business days for a response from a Proudly Assisting The Seniors (PATS)
team member. If you have questions regarding this application, please feel free to contact
us via email at [email protected] or by phone on Monday-Friday from 10:00 a.m. to
3:00 p.m. at 313-288-2449.
I certify, under penalty of perjury, that the answers I am about to give are correct and complete to the best of my knowledge.

Your Signature Signature Today’s Date Date
Signature of Person, If Any, Who Helped Complete the Form signature
Today’s Date Date
Print Name of Person Who Helped Complete Form signature
Today’s Date Date
Mailing Address of Person Who Helped Complete Form signature
Address:Street Address Address Line 2 City State Zip
checkbox *

By checking this box and typing my name in the “Your Signature” box above, I am electronically signing this document. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
STAFF USE ONLY: DATE RECEIVED: Date

Open Closed Date
Please verify that you are human *
Should be Empty:

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