Financial Assistance form

Name*

First Middle Last

Email*

Please confirm email*

Phone*

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Birth Date*

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

County*

CCM provides services to residents of CABARRUS COUNTY and those within KANNAPOLIS CITY LIMITS. If you reside outside of these areas, please do not complete this application.

CCM’s financial assistance is only offered to Cabarrus County and Kannapolis City limit residents. Please use the following link to find services in your area. https://www.findhelp.org/

Please explain IN DETAIL the reason that you are seeking assistance and what has made you fall behind.*

Please list the Name and Ages of all Household Members.*

Race/ Ethnicity of Applicant*

Marital Status*

Single
Married
Divorced/Separated

Spouse Name*

Gender*

Male
Female

Has your household received financial assistance from CCM in the past 2 years?*

Yes
No

We will not be able to assist you - CCM’s financial assistance is offered once every 2 years. Please use the following link to find other services that may be able to help you. https://www.findhelp.org/

Number of people in your household*

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Is there someone in your household who is currently pregnant?*

Yes
No

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Are there children in your household ages 0 to 4 years old?*

Yes
No

Please select sources of ALL household income.*

Earned Income
Social Security Benefits ( SSDI, SSI, SSA)
Unemployment Benefits
Child Support
No Income
Other

Type of Assistance needed:*

Rent
Utilities
Mortgage
Auto
Other

How much assistance are you requesting?*

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How much assistance are you requesting for Rent?

Please enter the dollar amount that you need

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How much assistance are you requesting for Utilities?*

Please enter the dollar amount that you need

CCM's maximum assistance amount is $500.00. This is for all types of financial assistance. Are you able to pay the difference of the balance owed BEFORE we process our payment?*

Yes
No

The maximum amount of financial assistance CCM is able to provide is $500.00 toward any requests. We cannot process a payment until you have paid the remaining portion of the balance due. As you indicated that you are unable to pay the difference at this time, we are unable to proceed with your request. You are welcome to reapply if your circumstances change and you are able to cover the difference. However, please understand that reapplication does not guarantee assistance.

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Do you own or rent your home?*

own my home
rent my home

WE NOT HAVE HAVE FUNDING TO ASSIST WITH MORTGAGES - ONLY PAST DUE RENT

Is the lease in your name or your spouse/partner's name?*

Yes
No

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Have you been served an eviction notice?*

Yes
No

Is the bill in your name or your spouse/partner's name?*

Yes
No

Are you an authorized user on the bill?*

Yes
No

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Do you have a disconnection date for the utility?

Yes
No

Please provide name of Property Management Company /Landlord and contact information for them ( email and phone)*

Full Time or Part Time Employment?*

Full Time
Part Time

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Monthly Gross Income ( Before Tax)*

Monthly Net Income ( After Tax)*

Monthly Benefit Amount*

Weekly Benefit Amount*

Monthly Child Support Payment Amount*

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Do you receive any of the following?

Food Stamps (SNAP)
Medicaid
WorkFirst participant
WIC

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To attach documents - From your cell phone - take a picture of the document with your phone. Then, click on the 'Drop files here or Select files' area below to attach the picture. - From your computer/scanner - scan the document to your desktop. Click on the 'Drop files here or Select files' area below and search the Desktop for the document. Then, attach. If you have issues with file size and you have an iphone, please use the camera in your notes app and scan the document. The file size is much smaller than a picture.

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Please upload proof of income FOR ONE MONTH- PDF*

Drop files here or

Max. file size: 64 MB.

For IPhone users - If you have issues uploading your documents, please use the camera in your notes app and scan the document. The file size is much smaller than a picture.

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Please upload copy of most recent COMPLETE bank statement (ALL PAGES)- PDF*

Drop files here or

Max. file size: 64 MB.

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Please upload copies of MOST RECENT bill statements- PDF*

Drop files here or

Max. file size: 64 MB.

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Please upload copies of MOST RECENT late notice or rent ledger- PDF*

Drop files here or

Max. file size: 64 MB.

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Please upload a copy of your picture ID*

Max. file size: 64 MB.

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Interview Preference

Phone
In - Person

Psalms 17:6 I call on you, my God, for you will answer me; turn your ear to me and hear my prayer. CCM Staff and Volunteers would like to pray for you. Please list any prayer request, thanksgivings, or praises we may lift up.

Consent*

I agree to the CCM Consent Form.

1) When you apply at CCM for assistance, we record the names, birth dates, social security numbers, and addresses of everyone in your household. It is your responsibility to provide this information and any other documentation we deem necessary to make a decision about your request.

2) This information may be shared with other organizations and service providers in our community. Organizations that we coordinate services and resources with include, but are not limited to, Cabarrus and Rowan Depts. of Social Services, the Salvation Army, Community Free Clinic, and area churches.

3) In order to help you, we may also need to contact your landlord, mortgage holder, utility company, oil company, employer, pharmacy, or any other resource providers for any reasonable purpose to help make a decision about your application and resolve your crisis.

4) If you contact a church or other organization for help, either now or in the months to come, that church may call CCM to verify your situation. By signing below, you give us permission to share information in your file with that church or organization.

5) I understand that by signing below, I am giving Cooperative Christian Ministry permission to obtain information pertaining to my household from the Cabarrus County Department of Human Services, which will include, but is not limited to, the Crisis Financial Assistance, Crisis Intervention, and Low Income Energy Assistance Programs.

6) CCM reserves the right to refuse its services (both now and in the future) to anyone under or appearing to be under the influence of alcohol and /or drugs, displaying a rude and/or threatening behavior or to any person who gives false, fraudulent, or misleading information to the Cooperative Christian Ministry for the purpose of obtaining assistance.

7) I certify that all information submitted/provided on this application is correct, to the best of my knowledge.

You have the right not to permit us to share any information with the organizations, businesses, and resources listed above, however, if you choose not to sign this Consent and Release Form, CCM cannot help you.

This Consent and Release Form is valid for two years from the last date signed. If you wish to revoke this consent and release, please contact our office.
*I authorize CCM to provide information to the above stated agencies and resources for the purpose of verifying information, determining the amounts required, committing funds, and paying bills in order to act on my application and in response to other organizations which I have approached for help.

Comments

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Financial Assistance Application