APPLICATION REQUEST FORM (Waiting List)

Flagler Cares CRF Assistance Program Waiting List

Please fill out the form below to request that an application be emailed to you.   The application can be completed and signed online and submitted with the required documents.  (Please note that the application is not automated, staff will generate a custom application for you and you will receive an email when it is ready. It may take up to 24 hours depending on when you complete this form. Please do not fill out the form more than once).
What Documents Do I Need?
Paper applications are also available, learn more here.  Please note that households ONLY needing assistance with utilities will NOT be eligible unless they have received a shut off notice.

All individuals over age 18 in the household must complete and sign forms to complete the application process.  Please list ALL adults in the household below. Please make sure that all adults in the household check their email frequently to complete the application process.  Emails will come from Flagler Cares (echosign@echosign.com) and help@flaglercares.org.  Note:  If necessary, you may use the same email for multiple adults in the household but each adult must sign individually.

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* 1. Applicant/Householder

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* 2. Co-Applicant

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* 3. Other Adult 3

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* 4. Other Adult 4

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* 5. Other Adult 5

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* 6. How many children under age 18 live in the household?

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* 7. You must be at least one month delinquent on bills to receive assistance (rent, mortgage, and/or utilities)  Which bills are you delinquent on (list all)?  Please note that households ONLY needing assistance with utilities will NOT be eligible unless they have received a shut off notice.

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* 8. Have you received an eviction notice?

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