Golden Gap Foundation | Financial Assistance Application

Financial Assistance Application

Providing short-term bridge funding to help seniors access safe housing and care.

Applicant Information

Full Legal Name Date of Birth Last 4 of Social Security Number Current Address Phone Number Email Address

Representative Name Relationship to Applicant Legal Authority (POA, Guardian, etc.)

New Choices Waiver Assistance Veteran – Aid & Attendance Bridge Funding Other Emergency Senior Assistance

Describe Current Situation and Financial Need

Total Monthly Income Total Monthly Expenses Amount Requested What will the funds specifically cover?

Proposed Community or Care Provider Move-In Date Community Contact Name & Phone

I certify that the information provided is accurate and understand that assistance is subject to eligibility review and available funding.

Interested in working together? Fill out some info and we will be in touch shortly. We can’t wait to hear from you!