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    This online application may be completed using any of the following web browsers: Microsoft Edge, Google Chrome, Mozilla Firefox, or Safari.

    To qualify for the HOME Program, including Technology Services, you must be at least 60 years old and live within our service area.

    YesNo

    Unfortunately, you are not eligible for HOME Progam services at this time.

    If you have a disability and need help, consider contacting the Disability Hub at 1-866-333-2466 or visit them online at disabilityhubmn.org.

    Great! Now let's check to see if your location is eligible for HOME Program Services

    HennepinSherburneWright

    The HOME Program service area for your selected county includes the cities listed below. If your city is not listed, we cannot provide services to you currently. To find services available in your city, please call the Senior Linkage Line at 1-800-333-2433 or minnesotahelp.info.

    Great! You live in the service area. Now let's get additional information.

    To see if you may qualify for financial assistance through Title III, please follow these instructions to complete and return the Supportive Services Program Registration form from the State of Minnesota.

    1. DOWNLOAD & COMPLETE the form using the free Adobe Reader Software, or print and scan the completed form.
    2. SAVE THE COMPLETED FORM to your computer.
    3. Use the Select Files button, and select the form you just completed and saved.
    4. Click the Upload Files button to securely send the form to our staff as part of this application.

    If you are unable to upload the completed form,
    please print the form and mail it to our office at:

    Senior Community Services
    10201 Wayzata Blvd, #335
    Minnetonka, MN 55305

    DOWNLOAD THE INTERACTIVE SUPPORTIVE SERVICES PROGRAM REGISTRATION FORM

    Upload files
     

    YesNoI will send my Program Registration form by standard mailPlease contact me to complete the Program Registration form

    PLEASE CONTINUE YOUR APPLICATION REGARDLESS OF THE FILE UPLOAD RESULT

    Someone from our staff will contact you to complete this form once you've submitted your online application.

    Please continue completing your online registration for the HOME Program:


    You must be age 60 or older to be eligible for services.

    Non-HispanicHispanic or Latino


    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    How did you hear about the HOME Program?

    Just your street address, you've already entered your city and we know you live in Minnesota.

    5-digit zip


    Please let us know your housing situation.

    HousekeepingMinor RepairsPaintingHome Safety checksSeasonal Outdoor ServicesTechnology Support

    Please check ALL that apply to you.

    Veteran and Disability Status

    YesNo

    We may be able to give you more information about VA benefits if you need it.

    YesNo

    This information helps us serve you better.

    Emergency Contact Information

    Optional

    Required

    YOU MUST SUPPLY EMERGENCY CONTACT INFORMATION TO CONTINUE THIS FORM

    Please share your living situation and monthly income.

    I live aloneI live with my spouseI live with others

    Please let us know your monthly income so we can establish your eligibility for subsidies and rates for service(s).

    If you are married or live in a dual-income household, please let us know that persons' monthly income so we can establish your eligibility for subsidies and rates for service(s).

    Please include all routine monthly income in your calculations. Income sources include Social Security, pensions, annuities, PERA, IRA, retirement distributions or withdrawals, interest income, dividends, estate or trust, disability, Public Assistance, rental income, home equity funds, salary(ies), self-employment income, and all other income sources that are not a voluntary withdrawal of funds.

    Information for your spouse

    Non-HispanicHispanic or Latino

    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    YesNo

    We may be able to give you more information about VA benefits if you need it.

    YesNo

    This information helps us serve you better.

    Other Household Occupant Information

    Non-HispanicHispanic or Latino

    Type of phone you use

    Your main phone number

    Type of phone

    Alternate phone number

    YesNo

    We may be able to give you more information about VA benefits if you need it.

    YesNo

    This information helps us serve you better.

    Use of Information Statement

    I understand that the information I am providing on this form is for registration purposes. I certify that the information provided on this form is accurate and complete. I authorize Senior Community Services to verify this information, if necessary, and to provide this form to governmental entities as a condition of funding they provided to this agency. This information will not be released to anyone other than the above mentioned parties in a way that will identify me as an individual unless I sign a separate consent for that purpose.

    YesNo

    Download and view the Participant Bill of Rights

    YesNo

    Download and view the Non-Discrimination Agreement

    By typing your full legal name, you are providing a digital signature for this application.

    Most of our staff speak English, and we coordinate with interpreting services and culturally-specific community agencies to best serve our clients.

    Contact Us

    10201 Wayzata Blvd.
    Suite 335
    Minnetonka, MN 55305
    (952) 541-1019
    (952) 541-0841
    reimagineaging@seniorcommunity.org

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