WRAAA BENEFITS CHECKLIST

The White River Area Agency on Aging, Inc., has prepared this Benefits Checklist for Senior Citizens living in our 10 county area.  Please, note that any benefits this checklist displays is not a guarantee that you will be found eligible.  Some benefits can only be determined after a personal interview.  This is, however, a good starting point to help you determine what is available, and what, based on the information you provide, you may be eligible for.

Please fill out all fields to the best of your knowledge.  All fields are required.
Name:
 Age:

Marital Status:
Single/Divorced/Widowed Married 
Are you Homebound? 
Yes  No 

I live in the following county: Note: Due to variances in benefits eligibility requirements, benefits estimates can only be given for the counties in the WRAAA service area.

Monthly Household Income: $
Health Status:

Enrolled in Medicare? Yes No
Requires 24 hr. care? Yes No

Do you require help with one or more of the following activities? Bathing, Grooming, or Dressing Yes No
Do you require help with one or more of the following activities? Toileting, Eating, or Mobility Yes No

Assets: Assets generally include everything except your principal place of residence and the land it is ON and attached to. Separate property away from the residence counts as an asset, as do bank accounts, stocks, bonds, etc.

Total Value of Assets: $

 

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