MoTown Square

MoTown Square

Please complete the following form to express interest in MoTown Square AAL.

Full Name*

Date of Birth *

Home Address *

Street Address City, State and Zip Code

Mailing Address *

If Different than above

Email

Phone Number

Alternate Phone Number

What is your annual income?

Do you currently have a MI-CHOICE waiver?*

Yes

No

Have you been prescreened for MI CHOICE Medicaid Waiver by WM-AAA?*

WM-AAA is West Michigan Area Agency on Aging

Yes

No

Current Housing Status

Rent

Own

Unhoused

Other

If unhoused, have you completed an assessment through 211 or HAP?

Yes

No

Name of person or agency authorized to assist in application process.

Send me a copy of my responses

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