Application for Services

1 - General Information
2 - Services
3 - Your Rights
4 - Signature

Note: The following form is quite long because of all the information we need to collect to begin providing services to you.

All services are offered to residents of these counties:
Baldwin, Butler, Choctaw, Clarke, Coffee, Conecuh, Covington, Crenshaw, Escambia, Geneva, Marengo, Mobile, Monroe, Sumter, Washington & Wilcox.

If you do not live in one of the counties listed above or do not live in the state of Alabama, the only services we can provide at this time are Information & Referral services.

Fields marked with * are required.

First Name *

Last Name *

Street Address *

Street Address - Line 2

City *

State*

Zip *

Country*

Email *

Birth Date *

Age *

Phone Number (Primary) *

Phone Type *

Would you like to add additional phone numbers?
YesNo

Phone Number

Phone Type

Phone Number

Phone Type

Phone Number

Phone Type

Race/Ethnicity *

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteHispanic/Latino of any race or Hispanic/Latino onlyTwo or more races or ethnicitiesNot Known or Prefer Not to Say

Gender *

MaleFemaleGender not listed

Preferred Pronouns *

She, Her, HersHe, Him, HisThey, Them, Their

Optional - If you chose "Other" from above, please explain:

Describe how your disability affects your ability to function independently in your home, community, or work: *

How did you hear about us?

Living Arrangement *

I live in Assisted LivingI am living with Family or FriendsI live independentlyI live in a nursing homeI have other living arrangements than what is listed

Where does your income come from? *

My income comes from employmentMy income comes from Social SecurityMy income comes from Supplemental Security Insurance (SSI)My income comes from Social Security Disability Insurance (SSDI)My incomes come from more than one of the above.My income comes from none of the above sources

What is your monthly Income? *

Voting *

The National Voter Registration Act of 1993 (also known as the “NVRA” or “motor voter law”) sets forth certain voter registration requirements with respect to elections for federal office. Section 7 of the NVRA requires that States offer voter registration opportunities at certain State and local offices, including public assistance and disability offices. Please take a moment to complete the form. Voter Registration Declaration Statement If you are not registered to vote, we can provide a voter's registration application form to you. We will assist you in filling out the form, or you may fill it out privately. Applying to register, or declining to register to vote, will not affect the amount of assistance that you will be provided by this agency.

Would you like to register to vote?
I would like to register to voteI am already registered to voteI do not want to register to vote