Please Print

Name of Homeowner(s):  __________________________________________________

Street Address:  _________________________________________________________

City, State, Zip:  _________________________________________________________

Phone:  ____________________________________

Is the homeowner       low-income      60 or older      disabled      vetran/widow of vet

Pertinent information concerning homeowner(s) situation and home modifications that might be needed to keep them living in safety and aging in place (include names and ages of all people residing in the home):








What will the homeowner and family members do to help make the necessary home modifications?


Is the homeowner aware of this referral?    Yes      No

If the homeowner is 60 or over, are they willing to seek financial assistance from Henry County Senior Citizens and/or Alternatives for Older Adults?    Yes      No

Name of person submitting this referral:  _______________________________________________

Phone  ____________________________________  Date  ______________________________