Holiday Clearing House Senior Application 2025

Program Information

Please note:
The deadline for submitting the application is October 3, 2025.
At the end of this application, you will be asked to upload a picture of the front of your photo ID and one of each senior.

You must be:
A resident of Delaware County, OH
62 or older (with no children under the age of 18) or (with no school age children)
Living at or below 200% of the federal poverty level

We will be offering the option for clients to either pick up their items/meal from the PIN office or have items delivered to their residence. Pickups and deliveries will take place on December 11, 2025. If clients select to have items delivered, they will need to be home on December 11, 2025 to accept delivery.

If you are a senior and also the legal guardian of children, please fill out the Holiday Clearing House (HCH) Family Application instead of this application. This application is for seniors only. Children and families are served through the HCH Family Application. Please visit our website delawarepeopleinneed.org if you need to complete the HCH Family Application. Please complete only one application.

I verify that there are no children residing in my household.

* indicates required field

GENERAL INFORMATION

First Name *

Last Name *

Date of Birth *

Last four digits of SSN *

Household monthly income *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email *

HOUSEHOLD MEMBERS

How many people are living in your household? *

How many seniors (62+) are living in your household? *

SENIOR HOUSEHOLD MEMBER #1 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #2 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #3 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #4 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #5 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #6 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #7 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #8 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #9 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

SENIOR HOUSEHOLD MEMBER #10 INFORMATION

Household Member's First Name *

Household Member's Last Name *

Household Member's Birthdate *

Household Member's Relationship to you *

Pick up or Delivery

Please select one: *
I will pick up my holiday meal at the People In Need Office at 138 Johnson Drive, Delaware, OH 43015 on December 11, 2025.
Please deliver my holiday meal to my residence on December 11, 2025. A client must be present to accept the delivery.

Comments

Please list any additional pertinent information:

Eligibility

ANY FALSIFICATION OF INFORMATION PROVIDED ON THESE FORMS WILL AUTOMATICALLY DISQUALIFY YOU FROM ELIGIBILITY FOR ANY ASSISTANCE FROM PEOPLE IN NEED, INC. (PIN).

As required by Section 2.32 (a), Prohibition on re-disclosure - Rules.

This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person or persons to whom it pertains, or as otherwise permitted by such regulations. A general authorization from the release of medical or other information is NOT sufficient for this purpose.

Authorization

NOTE: All matters relating to client records are considered privileged and confidential and are treated as such by the employees of the Program. Information regarding such matters cannot be divulged without the consent of the client. Section 2.31 of P.L. 93-282.42 CFR. Part 2 requires the following information.

PEOPLE IN NEED, INC. OF DELAWARE COUNTY OHIO is hereby granted my permission to release to appropriate agencies, such information deemed necessary to facilitate my request for Holiday Assistance and collect necessary information from those appropriate agencies.

You will be asked to upload the supporting documentation for this application next.