PPSREA Retired Employees,Retired Employees Association

Service/Townsend Committee

Philadelphia Public School Retired Employee Association's

Service/Townsend Committee

Since 1947, the Philadelphia Public School Retired Employees Association (PPSREA) has been entrusted with the responsibility of providing financial support for our fellow retirees. Over the years, the Service/Townsend Committee has worked diligently to help members live in a safe, healthy and comfortable home environment. A sample of the many financial supports provided by the Service/Townsend Committee are:

• Care giver relief • In home appliances (e.g. Shower Chair, Wheelchair) • Home repair • Medical aides

• Occupational and Physical Therapy • Structural repairs for quality of life (e.g. Chair lift, Ramp)

To request support from the Service/Townsend Committee, please complete the Confidential Request for Service form

and return to the Office of PPSREA listed below.

THE PHILADELPHIA PUBLIC SCHOOL RETIRED EMPLOYEES ASSOCIATION

5398 Wynnfield Ave. - Suite 201 - Philadelphia, PA 19131-2344

CONFIDENTIAL REQUEST FOR SERVICE

Name ________________________________________ Date of Birth ______/______/______

Address________________________________________________ Apt__________________

City _____________________________ ST _______ Zip Code ________________________

Phone (_____) _____ - __________ Email address __________________________________

Year Retired __________ Years of Service ______________ Last Position _______________

Referred by ____________________________________________ Date: ____/____/_____

INCOME / FINANCIAL AID (Indicate monthly amount)

School District pension $__________________________

Social Security $ __________________________

Other pension(s) $__________________________

Describe:

Medicaid $ __________________________ Y _____ N

Other $ __________________________

Briefly describe the nature of service requested and the approximate cost. Continue to the other side of the page, if needed.

**3 estimates for contracted services must be obtained from licensed and insured contractors**

Please return this Request for Service to the office at the above address.

Any information provided will be held in the strictest confidence.

Region XI PASR

PASR