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FINANCIAL ASSISTANCE APPLICATION
Financial Assistance form
Last 4 Digits of SSN#
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Briefly describe your financial need.
Number of people in your household
How much assistance are you requesting?
Please enter the dollar amount that you need
Type of Assistance needed:
Is there income in the household?
Are you currently employed?
Full Time or Part Time Employment?
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.
Please upload proof of income
Drop files here or
Please upload copies of bill statements
Drop files here or
Please upload a copy of your picture ID
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, pharamcy, 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.
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.
This field is for validation purposes and should be left unchanged.