Aarp Foundation Web Based Scsep Application Form
ADVERTISEMENT
1
2
3
4
5
6
7AARP FOUNDATION
Web Based SCSEP Application Form
Welcome to Part 1: Eligibility Determination
DIRECTIONS: The first step is to determine if you are eligible for AARP Foundation SCSEP services. Please
print complete, and submit this Eligibility Determination application. When you have completed all of the
pages of the Eligibility Application, submit all pages of the application for review to the appropriate location
listed on the website:
Applications can be submitted via Mail, Fax, or as attachments to an Email. NOTE: Incomplete
applications that are submitted will NOT be reviewed. You will receive an email response once your
application of eligibility has been reviewed. Please allow up to 5 business days for a decision regarding your
application for Eligibility. If determined eligible, your next step will be to complete and submit part 2 of the
application.
APPLICANT INFORMATION
Application Date
Last Name
First
M.I.
Suffix
Street Address
Apt/Unit #
City
State
ZIP
County
State of Residence (if Different than Address)
Mailing Address (if different than Address)
City
State
ZIP
Home
E-mail
Cell Phone
Phone
Address
Male
Female
Date of Birth:
Age:
Married
Yes
No
Spouse’s Name
Spouse Date of Birth
Age:
How did you hear about AARP Foundation SCSEP?
Newspaper
TV
Flyer
Other
Radio
Friend
Presentation
Explain:
Employment Status:
Employed
Employed w/ Notice of Termination
Unemployed
# of Weeks Unemployed:
Were you previously a Participant in any SCSEP Project?
If yes, which SCSEP program and location?
Approx Date:
From:
To:
Enter # of people in your Household family
Just Myself
Myself and My Spouse
Myself and a Dependent(s)
Myself, My Spouse, and One or more Dependents
1
Revised: 9/21/2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical