Bergen County Division of Senior Services
Aging & Disability Resource Connection
MEALS ON WHEELS APPLICATION
Fax 201-336-7424 Tele. 201-336-7420
Unable to leave home without assistance
Able to leave home independently
Hard of Hearing
Visually Impaired
Oxygen User
Non-ambulatory
Wheelchair User
Walker/Cane User
Regular / Heart Healthy / No added salt
Special Diet
Special diets are not available
Live alone
Female Head of household
With spouse/domestic partner/civil union
With roommate/friend/family or other informal caregiver
Caregiver is not home during the day
Caregiver is home during the day
Applicant is caring for a disabled child
Front door
Back door
Side door
Ring Bell
Knock
Driver has key to door
Hispanic/Latino
Non-Hispanic/Latino
Male
Female
Intersex
Transgender
Other
American Indian/Alaskan Native
Asian
Black/African American
Pacific Islander/Native Hawaiian
White
Heterosexual/Straight
Lesbian/Gay
Bisexual
Unsure
If not listed above please specify
$0. - $1,132. Month (1 person household) / $0.00 - $1,525. Month (2 persons, FPL)
$1,133. - $2,754. Month (1 person, Elder Index) / $1,526.- $3,622. Month (2 persons, Elder Index)
$2,755. - Month or above (1 person) / $3,623. - Month or above (2 persons)