GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Division of Senior Citizen Affairs- Information and Referral Services SENIOR IDENTIFICATION APPLICATION NAME ________________________________________________________________________________________ Last First Initial SOCIAL SECURITY #________________ DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ CITIZENSHIP STATUS: A. Alien__ B. U.S. Citizen__ C. Resident Alien (Green Card) ___ ETHNICITY: A. Black____ B. Caucasian _____ C. Hispanic _____ D. …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://dhs.vi.gov/wp-content/uploads/2023/04/SCA_Senior_Identification_Application.pdf
SHA-256 10ca4c261985fe4451052d0cd3cce4a275871c8333ba9444b24f7322ccf1218c
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-10ca4c261985
Document text
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Division of Senior Citizen Affairs- Information and Referral Services SENIOR IDENTIFICATION APPLICATION NAME ________________________________________________________________________________________ Last First Initial SOCIAL SECURITY #________________ DATE OF BIRTH______________ PLACE OF BIRTH ______________ ADDRESS: (PHYSICAL) _______________________________________________________________________ (MAILING) _______________________________________________________________________ TELEPHONE NUMBER: (HOME) _____________ (WORK) _______________ (CELL) _______________ CITIZENSHIP STATUS: A. Alien__ B. U.S. Citizen__ C. Resident Alien (Green Card) ___ ETHNICITY: A. Black____ B. Caucasian _____ C. Hispanic _____ D. Other _____ MARTIAL STATUS: Married___ Single___ Divorced___ Widowed___ Separated ____ NAME OF SPOUSE / CONTACT PERSON: ___________________________________________ (H) _______________________ (W) ________________________ (CELL) __________________________ ADDRESS: _____________________________________________________________________________________ EMPLOYMENT STATUS: A. Unemployed ___ B. Part-time employment___ C. Retired____ D. Full-time employment___ E. Are you interested in Employment? Yes____ No _____ Name of Employer ____________________________________________________ Address ____________________________________________________________ Phone __________________ What is the state of your health? Fair ___ Good ___ Excellent ____ Average___ Poor___ Do you have any ailments? ________________________________________________________________________ Do you have difficulties taking care of yourself? Yes ___ No ___ If yes, what are those difficulties? __________________________________________________________________ Please list medications that you are currently taking? ______________________________________________ _________________________________________________________________________________________ What are your food/drug allergies? _______________________________________________________________ SERVICES RECEIVED/ NEEDED: Mental Health Services ___ Home Delivered Meals___ Homemaker Services___ Home Health Care ___ Income Maintenance ___ Adult Protective Services___ Housing ___ Educational (U. V .I.) ___ Medical Assistance ____ Social Security ___ Food Stamps ___