Todd Baird Lindsey Foundation

Todd Baird Lindsey Foundation P.O. Box 724 Carlisle, Pennsylvania 17013 Phone: (717) 486- 4121 Fax: (717) 486-3959 Application for Benefits

Name: ______Date: ______

Street Address: ______Township/Municipality: ______

Town: ______Zip code: ______How long at this address: ______

Phone number: ______Date of birth: ______

Social Security number: ______Primary insurance: ______

Secondary insurance: ______Prescription drug plan: ______

Physician: ______Phone number: ______

Marital status: ( ) Single ( ) Married ( ) Widowed ( ) Divorced ( ) Separated

If married, name of spouse: ______Date of birth of spouse: ______

Social Security # of spouse: ______Spouse’s primary insurance: ______

Secondary insurance: ______Prescription drug plan: ______

List the names and ages any other individuals in your household: ______

______

List one relative/alternate contact if we cannot reach you by telephone: Name: ______Relationship: ______Address: ______Phone: ______

Have you applied for assistance from any agencies or organizations in the past 5 years? ___yes ___no If yes, please list the agencies/organizations: ______

Do you receive any assistance from family and/or friends at this time? ___ yes ___ no If yes, please describe: ______

How did you hear about the Todd Baird Lindsey Foundation? ______Please list all your expenses: List any balance due Home Expenses (as of today) Mortgage $ ______per month $ ______Rent $ ______per month $ ______Lot Rent $ ______per month $ ______Maintenance $ ______per month $ ______Gas $ ______per month $ ______Oil/Kerosene $ ______per month $ ______Electric $ ______per month $ ______Water/sewer $ ______per month or quarter (circle one) $ ______Trash $ ______per month or quarter (circle one) $ ______Telephone $ ______per month $ ______Cell Phone $ ______per month $ ______Taxes Real estate $ ______per year $ ______Personal taxes $ ______per year $ ______Insurance Homeowner’s/Renter’s $ ______per year $ ______Life $ ______per month or year (circle one) $ ______HealthPremiums $ ______per month or year (circle one) $ ______Automobile Loan payment $ ______per week or month (circle one) $ ______Insurance $ ______per month, quarter, or year (circle one) $ ______Registration fees $ ______per year Repairs/inspection $ ______per year $ ______Fuel $ ______per week or month (circle one) Medical Doctor $ ______per month $ ______Dentist $ ______per month $ ______Hospital $ ______per month $ ______Medications $ ______per month $ ______Special: ______$ ______per month $ ______Personal Clothing $ ______per month or year (circle one) Food $ ______per week or month (circle one) Toiletries/personal care $ ______per week or month (circle one) Credit card payments $ ______per month $ ______Loans/Rental fees $ ______per month $ ______Miscellaneous TV and/or Internet Service $ ______per month $ ______Newspaper/magazines $ ______per year Legal fees/fines $ ______per month $ ______Charitable contributions $ ______per month or year (circle one) Cigarettes/alcohol $ ______per month Laundry/cleaning supplies $ ______per month Storage unit $ ______per month $ ______Please check the type of assistance you need at this time: ____ Rent ____ Gas bill ____ Mortgage/Loans ____ Lot rent ____ Oil bill ____ Homeowner’s insurance ____ Electric bill ____ Real estate taxes ____ Medical equipment ____ Hearing aid(s) ____ Housekeeping ____ Personal Emergency Response Service ____ Nursing visits ____ Prescriptions ____ Other, please explain: ______

Please list any past due bills and note if you have received a shutoff or foreclosure notice: ______

Please provide gross amounts of all sources of household income: Social Security $ ______per month Annuity $ ______per month Pension $ ______per month SSI and/or SSP $ ______per month Employment $ ______per month Social Security Disability $ ______per month Workman’s Compensation $ ______per month Unemployment Compensation $ ______per month Income tax refund $ ______current year Cash assistance $ ______per month Food stamps $ ______per month Rent/Property tax rebate $ ______current year Family/friend assistance $ ______per month Other: $ ______per month

Please list all your assets: Current value Location Checking account $ ______Savings account $ ______Certificate of deposit $ ______Life insurance $ ______Real estate $ ______Stocks/Bonds/Mutual Funds $ ______Annuity/Retirement/401K $ ______Other $ ______Automobiles $ ______Make: ______Model: ______Year: ______$ ______Make: ______Model: ______Year: ______

Applicant’s Declaration I verify that the statements in the foregoing Application for Benefits are true and correct. I understand that a false statement herein will cause my Application to be dismissed without any further consideration.

______Signature of Applicant Date Todd Baird Lindsey Foundation P.O. Box 724 Carlisle, Pennsylvania 17013

Name: ______Social Security #: ______

Address: ______

I hereby authorize and request the disclosure to the Todd Baird Lindsey Foundation and it’s representatives information concerning myself, including my age, residence, citizenship, employment, income, resources, liabilities, medical diagnoses, physician’s history and physical, current medications and any other necessary information required to determine my eligibility for assistance. It is understood that the information obtained will be used only for purposes directly related to my eligibility for benefits of the Todd Baird Lindsey Foundation and may be referred and provided to agencies from which I will be receiving benefits and services.

______Signature of Applicant Date

______Signature of Witness Date

At the request of ______(“Requesting Agency”) Todd Baird (Referral Agency) Lindsey Foundation may be reimbursing part of the cost of certain services provided to me through the Project S.H.A.R.E. or Maranatha (“Agency”). I understand that the Foundation is not a guarantor of any such services to me or for my benefit and that the reimbursement to the Agency for such services does not inure to any third party and is solely limited to those obligations arising out of the agreement by and between the Agency and Foundation for reimbursement of such services. I understand that the Foundation will not be the direct or indirect provider of any such services.

In consideration for the Foundation reimbursing the Agency for some of such services provided to me and intending to be legally bound hereby, I agree that I will hold the Foundation, its directors, employees, and agents and their heirs, executors, administrators, and assigns harmless from any and all claims, suits, causes of actions, damages, judgments and demands whatsoever that I may have, or which my heirs, executors, or administrators may have for, upon or by reason of any matter, cause or thing whatsoever arising from the services provided to me or for my benefit by any provider, its directors, employees or agents.

______Signature of Applicant Date

______Signature of Witness Date 12/10/14