SENIOR COMPANION PROGRAM VOLUNTEER APPLICATION

Background Check Consent

- Criminal background checks are required of all senior companions. By signing this application, I certify that I have not been convicted of murder or any type of sexual assault. I understand that my selection to be a Senior Companion is based on the results of my Criminal Background Checks.
- Falsifying or withholding information on the initial application or other information regarding eligibility is grounds for dismissal from the Senior Companion Program per Federal Guidelines, Senior Companion Manual, and Punishable Offenses Pg. 18 C.M.
SENIOR COMPANION SIGNATURE*field type signature
Date*field type date
SCP Project Staff Signaturefield type signature
Datefield type date

ATTACHMENTS TO BE INCLUDED WITH APPLICATION:

Copy of Driver's License or Texas ID Card*field type file upload
Drop files here
You have reached the maximum file limit: 10.
Copy of Current Liability Insurance*field type file upload
Drop files here
You have reached the maximum file limit: 10.
Most recent Social Security/SSI Income Letter*field type file upload
Drop files here
You have reached the maximum file limit: 10.
Any Other form of income you may be receivingfield type file upload
Drop files here
You have reached the maximum file limit: 10.

SENIOR COMPANION PROGRAM EMERGENCY/MEDICAL INFORMATION

EMERGENCY CONTACT INFORMATION
In case of emergency:
1st Contact Information
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Street Address*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Address Line 2field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State / City / Province*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Postal / Zip Code*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Cell Phone*field type single line
(000) 000-0000
Input blocked. Maximum character limit of 4000 characters reached.
Home Phonefield type single line
(000) 000-0000
Input blocked. Maximum character limit of 4000 characters reached.
Relationship*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
2nd Contact Information
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Street Address*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Address Line 2field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State / Province / Region*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Postal / Zip Code*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Cell Phone*field type single line
(000) 000-0000
Input blocked. Maximum character limit of 4000 characters reached.
Home Phonefield type single line
(000) 000-0000
Input blocked. Maximum character limit of 4000 characters reached.
Relationship*field type single line
Input blocked. Maximum character limit of 4000 characters reached.

MEDICAL INFORMATION

List Allergies: If none, type none*field type multi line
I'm being treated for the following conditions:field type checkbox
I'm being treated for the following conditions:ArthritisDiabetesHigh CholesterolOther

Medications

	Medication Namefield type multi line	Purposefield type multi line	Dosagefield type multi line	Prescribing Physicianfield type multi line
1×	Medication Namefield type multi line	Purposefield type multi line	Dosagefield type multi line	Prescribing Physicianfield type multi line	×
2×	Medication Namefield type multi line	Purposefield type multi line	Dosagefield type multi line	Prescribing Physicianfield type multi line	×
3×	Medication Namefield type multi line	Purposefield type multi line	Dosagefield type multi line	Prescribing Physicianfield type multi line	×
4×	Medication Namefield type multi line	Purposefield type multi line	Dosagefield type multi line	Prescribing Physicianfield type multi line	×

Click here to add more rows

STATEMENT OF CONFIDENTIALITY

All information, except for the medical information that will be given to the physician in case of emergency, is confidential and will be used only for the purpose of providing services to you, as a senior citizen, and for statistical information.
I, the undersigned, authorize the user of the information I have provided for the above stated purposes.
SENIOR COMPANION SIGNATURE*field type signature
Date*field type date

Informe Confidencial

Toda informacion, con excepcion de la informacion medica queue se dara en caso de emergencia,es confidencial y sera usada solamente para el proposito de proveerle servicios a used, como cuidadano mayor, y para informacion estadistica.
Yo, el subscrito, autorizo el uso de la informacion provoido para el proposito mencionado arriba.
FIRMAfield type signature
FECHAfield type date
STAFF SIGNATUREfield type signature
DATEfield type date

Is this a new applicant?*field type radio button
Is this a new applicant?YesNo

INCOME ELIGIBILITY FORM FOR SENIOR COMPANION VOLUNTEERS AND APPLICANTS

In order to receive a stipend, a Senior Companion must be at least 55 years of age and cannot have an annual income from all sources, after deducting allowable medical expenses, which exceeds the program’s income eligibility guideline for the state in which he or she resides. Annual income is required to be counted for the past 12 months for serving volunteers and is projected for the next 12 months for new applicants.
Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Phone Number*field type single line
(000) 000-0000
Input blocked. Maximum character limit of 4000 characters reached.
Date of Birth*field type date
Street Address*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Address Line 2field type single line
Input blocked. Maximum character limit of 4000 characters reached.
City*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
State / Province / Region*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Postal / Zip Code*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Number in household*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Martial Status*field type drop-down
In all categories below list all sources of income for the volunteer applicant and spouse, if living in same residence.

	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line	A. Volunteer's Monthly Income*field type currency	B. Spouse's Monthly Income*field type currency	C. Total Monthly Income (A+B)field type currency	field type single line	D. Total Annual Income (C x 12)field type currency
row 1	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line Input blocked. Maximum character limit of 4000 characters reached.	A. Volunteer's Monthly Income*field type currency $	B. Spouse's Monthly Income*field type currency $	C. Total Monthly Income (A+B)field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	D. Total Annual Income (C x 12)field type currency $
row 2	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line Input blocked. Maximum character limit of 4000 characters reached.	A. Volunteer's Monthly Income*field type currency $	B. Spouse's Monthly Income*field type currency $	C. Total Monthly Income (A+B)field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	D. Total Annual Income (C x 12)field type currency $
row 3	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line Input blocked. Maximum character limit of 4000 characters reached.	A. Volunteer's Monthly Income*field type currency $	B. Spouse's Monthly Income*field type currency $	C. Total Monthly Income (A+B)field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	D. Total Annual Income (C x 12)field type currency $
row 4	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line Input blocked. Maximum character limit of 4000 characters reached.	A. Volunteer's Monthly Income*field type currency $	B. Spouse's Monthly Income*field type currency $	C. Total Monthly Income (A+B)field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	D. Total Annual Income (C x 12)field type currency $
row 5	Current Income from all sources of Applicant and Spouse, if living in same residencefield type single line Input blocked. Maximum character limit of 4000 characters reached.	A. Volunteer's Monthly Income*field type currency $	B. Spouse's Monthly Income*field type currency $	C. Total Monthly Income (A+B)field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	D. Total Annual Income (C x 12)field type currency $

	field type single line	Volunteer's Total Incomefield type currency	Spouse's Total Incomefield type currency	Total Monthly Incomefield type currency	Total Annual Incomefield type currency
row 1	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Volunteer's Total Incomefield type currency $	Spouse's Total Incomefield type currency $	Total Monthly Incomefield type currency $	Total Annual Incomefield type currency $

Allowable deductions for medical expenses, if any. Please note up to 50% of the maximized qualifying amount can be deducted. See below for examples of allowable medical deductions

	field type single line	Per Month*field type currency	field type single line	Per Year*field type currency
row 1	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Month*field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Year*field type currency $
row 2	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Month*field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Year*field type currency $
row 3	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Month*field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Year*field type currency $
row 4	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Month*field type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Per Year*field type currency $

	field type single line	Total per monthfield type currency	field type single line	Total per yearfield type currency
row 1	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Total per monthfield type currency $	field type single line Input blocked. Maximum character limit of 4000 characters reached.	Total per yearfield type currency $

For Office Use Only:
Total Household Income:field type currency
$
Minus (-) Total Allowable Medical Exposure Deductionfield type currency
$
Equals (=) Total Annual Qualifying Incomefield type currency
$

I certify that the information furnished above is correct and understand that falsification of information may result in my being deemed ineligible to receive a stipend as a Senior Companion. I understand that a knowing and willful false statement on this form can be punished by a fine or imprisonment or both under Section 1001 of Title 18, U.S.C.
Volunteer Signature*field type signature
Date*field type date
Reviewed by Sponsor Stafffield type signature
Datefield type date
What is considered income for determining volunteer eligibility?
According to Section 2551.43 of the Senior Companion Regulations:
1. For determining eligibility, “income” refers to total cash or in-kind receipts before taxes from all sources including:
  (a) Money, wages, and salaries before any deduction, but not including food or rent in lieu of wages.
  (b) Receipts from self-employment or from a farm or business after deductions for business or farm expenses.
  (c) Regular payments for public assistance, Social Security, Unemployment or Workers Compensation, strike benefits, training stipends, alimony, child support, and military family allotments, or other regular support from an absent family member or someone not living in the household.
  (d) Government employee pensions, private pensions, and regular insurance or annuity payments; and
  (e) Income from dividends, interest, net rents, royalties, or income from estates and trusts.
2. For eligibility purposes, income does not refer to the following money receipts:
  (a) Any assets drawn down as withdrawals from a bank, sale of property, house or car, tax refunds, gifts, one-time insurance payments or compensation from injury.
  (b) Non-cash income, such as the bonus value of food and fuel produced and consumed on farms and the imputed value of rent from owner-occupied farm or non-farm housing.
What are allowable medical expenses that may be deducted from income?
According to the Senior Companion Regulations, Section 2551.42(c):
Allowable medical expenses are annual out-of-pocket medical expenses for health insurance premiums, health care services, and medications provided to the applicant, enrollee, or spouse which were not and will not be paid by Medicare, Medicaid, other insurance, or other third party pay or, and which do not exceed 50 percent of the applicable income guideline.
Examples of Allowable Out-of-pocket medical expenses:
Health Insurance Costs: Private Insurance, Medicare/Medicaid Premiums, Co-payments, and Deductibles
Prescription Drugs: Pharmacy Program Co-payments and Deductibles
Medical Bills for Dr. Visits: Included, but not limited to: Medical care, Dental Care, Vision Care
Other out-of-pocket Medical expenses: One-time medical expense; equipment (supplies for dentures, hearing aids, eyeglasses, wheelchairs, canes, etc) Over the counter drugs and supplies (pain relievers, antacids, hearing aid batteries, vitamins, non-prescription eyeglasses)
When and where are the current income eligibility guidelines published? The Corporation publishes the annual income eligibility guidelines shortly after the issuance of the HHS Poverty Guidelines, usually in February or early March. When issued the income eligibility guidelines are posted at www.seniorcorps.gov under “Manage Current Grants.” The guidelines clarify that for eligibility purposes, income does not include the value of food stamps provided under the Food Stamp Act of 1977, as amended.

If you have questions or need further clarification on determining income eligibility, please contact your CNCS State Office.
300 East 8th Street, Room G100
Austin, Texas 78401-3747
(512) 916-7003

Thank you for your interest
You will receive a reply within three business days. If you have any questions,
please send an email to JeannieL@cctexas.com or LindaR@cctexas.com, or call
(361) 826-3154
Corpus Christi Parks & Recreation - Senior Companion Program
1414 Martin Luther King Drive, Corpus Christi, Texas 78401 | (361) 826-3154
Parks Supervisorfield type drop-down

SENIOR COMPANION PROGRAM VOLUNTEER APPLICATION

PLACE OF BIRTH

WORK HISTORY

Background Check Consent

ATTACHMENTS TO BE INCLUDED WITH APPLICATION:

MEDICAL INFORMATION

Medications

STATEMENT OF CONFIDENTIALITY

Informe Confidencial

INCOME ELIGIBILITY FORM FOR SENIOR COMPANION VOLUNTEERS AND APPLICANTS