Financial Assistance Form

SUPPORTING DOCUMENTS MUST BE APPLIED FOR APPLICATIONS TO BE CONSIDERED. APPLICANTS WILL BE NOTIFIED OF A DECISION WITHIN 3-5 BUSINESS DAYS.

* Indicates required field

Today's Date *

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Employer *

Supporting Documents (Past Due Statement/Invoice, Driver License, etc) *

Max file size: 20MB

Marital Status *

Name(s) and Age(s) of Children Living at this Address: *

Name(s) and Age(s) of Other Adults Living at this Address: *

Total Monthly Expenses (Rent/Mortgage, Electric, Water, Car, Insurance, Phone, etc): *

Requested Type of Financial Assistance and Amount: *

How Do You Plan to Pay this Bill and Others in the Future: *

Monthly Income and Assistance for all Household Members: *

What is the reason for the request *

Submit

The Community Services Organization Assistance Network, hereinafter referred to as 'CharityTracker', is a shared, computerized record keeping system that captures
information about people experiencing need for emergency services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc.
Beaufort County Human Services Alliance (Administrating Agency) administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including HELP Of Beaufort (Participating Agency).
I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I have had an opportunity to ask questions
about CharityTracker and to review the basic identifying information, which is authorized by this release for the CharityTracker Assistance Network Participating
Agencies to share. I also understand that information about non-confidential services provided to me by CharityTracker participating agencies may be shared with other
CharityTracker Participating Agencies.
This Release of Information will remain in effect
for 3 years from the date noted under my signature at the bottom of this page unless I make a formal request to this Organization that I no longer wish to participate in
CharityTracker.

I authorize HELP Of Beaufort, as a CharityTracker Participating Agency, to share my basic, identifying and non-confidential service transactions/information with other
CharityTracker Participating Agencies. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize HELP Of Beaufort (Participating Agency), as a CharityTracker Participating Agency, to share my
dependent's basic, identifying and non-confidential service transactions/information with other CharityTracker participating agencies.

I have read the information release

Please click the checkbox than the submit button on the right

Financial assistance form

SUPPORTING DOCUMENTS MUST BE APPLIED FOR APPLICATIONS TO BE CONSIDERED. APPLICANTS WILL BE NOTIFIED OF A DECISION WITHIN 3-5 BUSINESS DAYS.