Thank you for your interest in receiving Emergency Assistance through the Brevard County Community Action Agency.

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1 Housing & Human Services Department Community Action Agency 400 South Varr Avenue Telephone: (321) Cocoa, Florida Fax: (321) Thank you for your interest in receiving Emergency Assistance through the Brevard County Community Action Agency. All ITEMS LISTED ARE NEEDED TO DETERMINE ELIGIBILITY FOR EMERGENCY SERVICES AND YOU MUST HAVE ALL DOCUMENTS AT TIME OF APPLICATION. 1. YOU MUST POSSESS TWO OF THE FOLLOWING ITEMS AS PROOF OF INTENT TO RESIDE IN BREVARD COUNTY: (bring with you) a. State of Florida Drivers License or Florida Identification Card for all adult household members with a Brevard County address. AND b. Proof of Employment or two (2) current consecutive months (in your name) utility bills or voter registration or yearly lease on rental unit. 2. ORIGINAL SOCIAL SECURITY CARDS FOR ALL HOUSEHOLD MEMBERS. 3. BIRTH CERTIFICATES FOR ALL OF THE CHILDREN THAT ARE LISTED ON THE APPLICATION. 4. PROOF OF ALL HOUSEHOLD MEMBERS INCOME FOR THE LAST SIXTY (60) DAYS: Paycheck stubs, Unemployment Compensation payment history, Veteran s check, Child Support payment history, AFDC/TANF, SSI, SSD, or statement from employer stating gross income. If you are receiving Unemployment Compensation Benefits you will need to call for a payment history. 5. ALL RECENT BANK STATEMENTS FOR THE PAST 60 DAYS: For all household members: Savings account, Checking account, or CD s. (The Bank Statements must be within 1 week of the application) 6. PROOF OF ALL MONTHLY BILLS AND EXPENSES FOR THE LAST SIXTY (60) DAYS: You must also provide receipts for payments of those bills/expenses. (Rent, electric, water, phone, gas, cable, car payments, insurance payments, furniture payments, prescriptions, child care, etc ) 7. IF YOU ARE LIVING WITH SOMEONE ELSE: You must provide a statement from them explaining your living arrangements and your financial obligations. 8. IF UNEMPLOYED: If you are not involved in the Wages program, you must be actively seeking employment. You must be registered at Job Link and bring two (2) job referrals. 9. IF YOU ARE UNABLE TO WORK: If it is due to disability or injury, you will be required to provide a statement from your physician. Mortgage/Rental Assistance For mortgage assistance, you must have a current statement from the mortgage company showing the amount that is due. For rental assistance, you must have a current yearly lease and a statement from the landlord showing the amount that is due. Utilities (electric, water, or gas) For utilities assistance, you must have utility bill. **Incomplete applications will not be accepted You must have all documents. **Please allow up to (21) days for processing once you submitted your completed application.

2 Brevard County Housing & Human Services Department Community Action Agency Last Name First Name Maiden Name Social Security # Street (current Living Address) City Zip Phone # Cell# HEALTH INSURANCE RACE FAMILY STATUS SPECIAL NEEDS TYPE OF ASSISTANCE OR SERVICE REQUESTED Private Medicaid Medicare Healthy Kids Stay Well Kid Care None Other White Black Hispanic Amer-Indian Asian Other Married Separated Widowed Deserted Single Divorced Farm Worker Homeless Medically Disabled Developely Disabled Mortgage Rent Water Utilities Electric Utilities Gas Utilities Burial Cremation RX HCRA Other HOUSEHOLD MEMBERS Names D.O.B SS# Sex Race Employed Grd lvl Relationship Page 1 of 3

3 MONTHLY INCOME: Employment Social Security AFDC/TANF VA Retirement Unemp. Comp. Workman s Comp Child Support Rentals Other LIQUID RESOURCES: Savings Checking TOTAL: Eligibility Level: TOTAL RESOURCES FOR THE MONTH Are you, or any member of your household, receiving FoodStamps? Yes No If so, how much? Have you or your spouse ever served in the Military? Yes No What problems or difficulties forced you to request assistance? MONTHLY PAYMENTS: MONTHLY PAYMENT Rent/Mortgage Electricity Water BALANCE DUE Gasoline Transportation Health Ins. Gas Furn/Wash/Dryer Medical Credit Cards Medical Bills Loans Insurance Food/Misc Child Care Phone Child Support Cable Car Payment Other Car Insurance TOTAL MONTHLY PAYMENT BALANCE DUE Resident or intend to reside in Brevard County: Yes Eligible Non Eligible No Page 2 of 3

4 FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I hereby authorize the investigation and verification of same with my employer, bank, or other sources. I understand that intentionally providing false information to obtain financial assistance is grounds for denial. Any person who knowingly, by false statement, misrepresentation, impersonation, or fraudulent means fails to disclose a material fact used in making determination as to such person s qualification to receive aid or benefits under any state or federally funded assistance program, or who knowingly fails to disclose a change in circumstances in order to obtain or continue to receive under any such program aid or benefits which he/she is not entitled to or in an amount larger than that to which entitled, or who knowingly aid and abets another person in the commission of any such act is guilty of a crime, and shall be punished as provided in F.S. Chapter Subsection 5. Client Date Eligibility Specialist Date Page 3 of 3

5 Housing & Human Services Department Telephone: (321) Community Action Agency Fax: (321) South Varro Avenue ocoa, Florida BREVARD COUNTY HOSUING & HUMAN SERVICES COMMUNITY ACTION AGENCY SELF DECLARATION OF INCOME I,, hereby certify that I am unable to provide written documentation of my income due to the following reason(s): I CERTIFY THAT THE INFORMATION I HAVE DISCLOSED IS TRUE AND ACCURATE. I UNDERSTAND THAT INTENTIONALLY PROVIDING FALSE INFORMATION TO OBTAIN FINANCIAL ASSISTANCE IS GROUNDS FOR DENIAL OF ASSISTANCE, AND MAY BE GROUNDS FOR PROSECUTION UNDER FLORIDA STATUES OR Client Signature Date