Must have someone aged 60 years or older living in your household to be eligible for service through Lorain County Office on Aging.

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Must have someone aged 60 years or older living in your household to be eligible for service through Lorain County Office on Aging. -

Lorain County
Office on Aging

(440) 326-4800

534 S Abbe Rd.
Elyria, OH 44035

Name

First Name

Last Name

What assistance do you need?

Spouse/Partner's Name (if applicable)

Are you homeless or at risk of becoming homeless?

Street Address

If homeless, please write "homeless" into following each address field.

Apartment/Lot Number

City

Zip Code

Phone

(###)

###

####

Is it okay to leave you a message at the number provided?

Date of Birth

Number of Seniors (60+) in Household:

Number of Adults (18-59) in household:

Number of Children (age 17 and under) in household:

Total Gross Monthly Household Income :

Income Source(s):

Employment/self-employment

SSI/SSDI

Unemployment

Worker's Compensation

Child Support

Retirement

None

Other: please state below

If "Other" was selected above, state here:

Have you applied for unemployment?

Do you make rent or mortgage payments?

How much do you pay a month for rent/mortgage?

How much do you pay a month, on average, for utilities?

How much do you pay for any other monthly expeses?

Briefly describe your current assistance needs and please specify how far behind you are on any bills:

Are there any deadlines you need to meet, such as a disconnect notice or court date? Please describe.

Please list the best times for the agency to call you:

Morning/afternoon/evening, or specific times.

If you are currently working with a case manager, please include their name and phone number:

Do you feel safe in your home?

If no, please contact Genesis House Lorain County Safe Harbor

24 Hour Hotline: (440)244-1853 http://www.genesishouseshelter.org/

http://

What is the name of the landlord/utility company you need assistance paying?

By including my utility company or landlord name above, I understand I am giving permission for the case manager to communicate with them for up to 30 days for my billing history, where possible.

Agree