Senior Application Name(Required)Primary household member if more than one person in the home. First Last Living Situation(Required) Live Alone Live with Family Home Location(Required) Private residence Clairemont Oaks Decatur Housing Authority (Oliver House) Park Trace Phillips Tower Other Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone(Required)Email Alternate ContactAlternate Contact Name(Required) First Last Alternate Contact Phone(Required)Alternate Contact Email Wish ListsClick the Add Wish List button to create one wish list per household member. Wish ListEnter one wish list per household member. Recipient Name Gender Age Actions Edit Delete There are no Wish Lists. Add Wish List Maximum number of wish lists reached. Preparer NameName of the preparer of the form if not the recipient. First Last Preparer Signature(Required)I understand that this application is for assistance only, not a promise of aid. I understand that I must follow the ASOG/Christmas Decatur guidelines in regard to this application. I understand that incomplete applications will not be considered.
