Benefits Access Survey

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- Culturally and Linguistically Appropriate Service
- Online Resources
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About Us
Leadership
MEMBERSHIP
SRC Initiatives

Benefits Access Survey

ASIDE FROM providing information and referral services, please indicate which of the following benefits your organization either helps consumers access (eg. application assistance) OR provides the service directly.

* Indicates required field

Organization: *

Name: *

First

Last

PLEASE INDICATE ALL THAT APPLY. IF YOU ARE NOT CERTAIN, DO NOT CHECK.

1. FOOD ASSISTANCE *

Food Stamps (Bridge Card) Congregate Meals - Nutrition Double Up Food Bucks Home-Delivered Meals Project Fresh Other:

(provide additional information here) *

2. TRANSPORTATION *

DDOT - Senior Pass Assistive Transport Services Metro Lift SMART Other:

(provide additional information here) *

3. HOUSING *

Section 8 Other:

(provide additional information here) *

4. HEALTHCARE *

Federally Qualified Health Clinic Medicare Medicaid Savings Plan Medicaid Cash Assistance Veteran's Health Benefits MI RX Card Veteran Administration's Health Care System Healthcare Navigation Other:

(provide additional information here) *

5. HOME SUPPORTS *

Home Care Assistance Home Chores Other:

(provide additional information here) *

6. HOME OWNERSHIP *

Property Tax Relief Veterans Home Assistance Weatherization Other:

(provide additional information here) *

7. UTILITY *

Home Heating Tax Credit Low Income Home Energy Assistance Program (LIHEAP) Other:

(provide additional information here) *

8. LEGAL/MEDICAL AFFAIRS - MANAGEMENT *

Guardian (PERS) Other:

(provide additional information here) *

9. INCOME ASSISTANCE *

Low-Income Subsidy Social Security - Retirement/Survivors Social Security - Disability Supplemental Security Income (SSI) Retirement Pension Temporary Assistance to Needy Families (TANF) VA Compensation Railroad Retirement Program Federal Retirement Program Volunteer Stipend Workmen's Compensation Unemployment Benefits State Emergency Relief (SER) Other:

(provide additional information here) *

10. EMPLOYMENT *

Senior Community Service Employment Program (SCSEP) Work Income/Employment Other:

(provide additional information here) *

11. NURSING HOME & LONG TERM CARE ISSUES *

Veterans HOME Program Nursing Home Medicaid - Spousal Impoverishment Mi Choice Waiver Program Other:

(provide additional information here) *

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