FINANCIAL FORM
VIRGINIA M. SCHROEDER RESPITE CARE FUND
Please fill out the application.
Print it out When the application is complete, send by
fax to (203) 316-8614 or by mail to InterFaith Council of Southwestern
Connecticut, One Canterbury Green, Box #7, Stamford, CT 06901. The
information that you provide will be held confidential by the clergy and the members of the InterFaith Council who process it.
Individual Receiving Care
Date Form Completed
Caregiver's Name
(include your relationship)
Address of person cared for: Street Address
City, State, Zip
Does Caregiver reside at same address Number of people in household
Does caregiver work full time? Part time
Household income from all sources: state whether monthly (M) or annual (A).
Wages
Social Security
Pension
Alimony or child care
Investments
Property rentals
Other
Current expenses: state whether monthly (M) or annual (A)
Mortgage or rent
Utilities
Taxes
Insurance:
Medications/doctors Schools