1.Relationship to participant: (Please choose one)

Self

Spouse/Significant Other

Family Member

Friend/Neighbor

Division of Aging staff with participant

Other

2.Age of Money Follows the Person participant:

3.Gender of Money Follows the Person participant:

Male

Female

*4.What is your or the Money Follows the Person participant’s local Area Agency on Aging or Independent Care Agency? If you are unsure please select N/A.(Required.)

Area 1: Northwest Indiana Community Action Corporation - Includes counties: Jasper, Lake, Newton, Porter, Pulaski, Starke

Area 2: REAL Services Inc. - Includes counties: Elkhart, Kosciusko, LaPorte, Marshall, St. Joseph

Area 3: Aging and In-Home Services of Northeast Indiana Inc. - Includes counties: Adams, Allen, DeKalb, Huntington, LaGrange, Noble, Steuben, Wells, Whitely

Area 4: Area IV Agency on Aging & Community Action Programs, Inc. - Includes counties: Benton, Carroll, Clinton, Fountain, Montgomery, Tippecanoe, Warren, White

Area 5: Area Five Agency on Aging & Community Services Inc. - Includes counties: Cass, Fulton, Howard, Miami, Tipton, Wabash

Area 6:  LifeStream Services Inc. - Includes counties Blackford, Delaware, Grant, Henry, Jay, Madison, Randolph

Area 7: West Central Indiana Economic Development District, Inc. - Includes counties: Clay, Parke, Putnam, Sullivan, Vermillion, Vigo

Area 8: CICOA Aging & In-Home Solutions - Includes counties: Boone, Hancock, Hamilton, Hendricks, Johnson, Marion, Morgan, Shelby

Area 9: LifeStream Services Inc. - Includes counties: Fayette, Franklin, Rush, Union, Wayne

Area 10: Area 10 Agency on Aging - Includes counties:  Monroe and Owen

Area 11: Thrive Alliance - Includes counties: Bartholomew, Brown, Decatur, Jackson, Jennings

Area 12: LifeTime Resources Inc. - Includes counties: Dearborn, Jefferson, Ohio, Ripley, Switzerland

Area 13: Generations Vincennes University Statewide Services - Includes counties Daviess, Dubois, Greene, Knox, Martin, Pike

Area 14: Lifespan Resources Inc. - Includes counties: Clark, Floyd, Harrison, Scott

Area 15: Hoosier Uplands/Area 15 Agency on Aging and Disability Services - Includes counties: Crawford, Lawrence, Orange, Washington

Area 16: SWIRCA & More - Includes counties: Gibson, Perry, Posey, Spencer, Vanderburgh, Warrick

N/A

Independent Care Agency (please specify)