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Fill out this assessment and attach the relevant documentation to be considered for rent or utilities assistance.

Once the assessment is received with the complete information and documentation, then a Ocoee Connect staff member will be in contact letting you know whether or not you are eligible for assistance.

It is essential that the information is filled out completely with the supporting documentation. Thank you!

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* 1. Contact Information

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* 2. What is your date of birth? 

Date

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* 3. Please enter the last FIVE (5) digits of your Social Security Number.

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* 4. Gender

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* 5. Ethnicity

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* 6. Have you ever served in the military?

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* 7. Including yourself, how many people live with you?

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* 8. How many children (under 18) are in your household?

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* 9. Are you currently employed?

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* 10. If you are employed, where do you work?

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* 11. Have you recently been laid off, furloughed, on FMLA or let go?

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* 12. What is your approximate average household income?

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* 13. Please include your source(s) of income (check all that apply)

Please upload proof of income prior to loss of income. (You may upload up to 5 documents below)

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* 14. Please upload documents to verify income lost.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 15. Please upload documents to verify income lost.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 16. Please upload documents to verify income lost.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 17. Please upload documents to verify income lost.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 18. Please upload documents to verify income lost.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 19. Is your reduction in work due to COVID-19? *

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* 20. What is your situation? Why do you need assistance?

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* 21. What type of assistance do you need? (Choose all that apply.)

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* 22. Are your utilities already cut off?

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* 23. Utility Information

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* 24. If you need rent assistance, what is your landlord's name and contact information? (If seeking rent assistance.)

Please upload related utility and rent documents (You may upload up to 5 below)
Also include proof of loss of income and unexpected expenses in the fields below. Please include clear pictures with account numbers showing.

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* 25. Please upload related utility and rent documents.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 26. Please upload related utility and rent documents.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 27. Please upload related utility and rent documents.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 28. Please upload related utility and rent documents.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 29. Please upload related utility and rent documents.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
 
The information in this form will be used in our Charity Check system. By clicking Finish below, you certify that all of the above information listed is true and correct. I understand that I may be disqualified from receiving assistance by making false statements or from the withholding of documentation. I hereby authorize Ocoee Connect to obtain and/or release any information from and to any source pertaining to my request for assistance. Ocoee Connect enters all gift data or gift denials into the Charity Check system as well as the information provided on this intake form. I understand that my photo or photo ID may accompany my information in Charity Check. This is a data sharing network in cooperation with churches and human service agencies.

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