$100 Visa Gift Card ProgramFor Low-Income Seniors (65+) Apply Now Once you fill out the form below, click submit and we’ll be in touch! Name * First Name Last Name Phone * A phone number we can reach you directly: (###) ### #### Can we text you? * Yes No Email * Address: * Current address you are physically living at? Address 1 Address 2 City State/Province Zip/Postal Code Country AGE? * Monthly Income Amount: * Total combined monthly income from all income sources: Monthly Bills Total: * Your combined bills total: When is a good time for us to call? * Do you have or receive any of the following? Select all that apply. Medi-cal Medicare Part A Medicare Part B Medicare Part C or D Other Insurance Receiving Food Stamps Free Government Phone Who helped you today? If someone helped you fill out this form, please list their name. Source of Income * We need to know how much money you receive monthly to qualify as Low-Income. Social Security Other: Employment CONGRATULATIONS!!! We have successfully received your application! We’re on it and excited to welcome you into our community!
