Historic Eastside Community Support Application

Community Support Intake Form

Thankk you for taking the first step towards support. This form helps us understands your needs so we can connect you with the right resources. All information is kept confidential in accordance with privacy protections. If you have any questions please call 904.328-6034. Monday - Friday 9 a.m. - 3 p.m. or email us at eastside@hecdcjax.org.
How can we support you?*
Services are provided through Historic Eastside CDC and trusted partners. Programs are designed to help residents prosper in place, protect generational assets and benefit from neighborhood revitalization
If Other specify here
Name*

First NameMiddle NameLast Name
SECONDARY PHONE NUMBER
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
PRIMARY PHONE NUMBER*
Please enter a valid phone number.
Preferred Method of Contact*

PhoneTextEmail
Date of Birth*

MonthDayYear
Date
Social Security Number
Gender*
Head of Household*

YesNo
Age*
Disabled*

YesNo
Military/Veteran*

ActiveRetiredNot Military
Housing Status*

RentHomeownerHomelessLiving with others
Household Size ( total people in household)*
How Many Children Under 18*
Primary Mode of Transportation
Martial Status*
Education*
Source of Income*
If Employed, Please List Job Title, Name of Employer, Occupation and How Long Employed
Annual Gross Household Income*
Monthly Net Income (after taxes)*

BUDGET (place 0 if not applicable)*

Do You Own Your home?*
Do You Want To Buy A Home
Do You Own A Business ( Optional)
If Yes What Type of Assistance Is Needed
What is Your Credit Score?*
Have You Pulled Your Credit Score Within The Past Three Months: *
(request) for free at: www.annualcreditreport.com
How did you hear about Historic Eastside CDC

Family/FriendCommunity EventFlyer/PosterInternet SearchPartner OrganizationSocial MediaOther
I GIVE MY CONSENT FOR THE HISTORIC EASTSIDE CDC, HOUSING COUNSELING STAFF OR REPRESENTATIVE TO CREATE A MANUAL AND ELECTRIC CLIENT MANAGEMENT / TRACKING FILE TO USE PERSONAL DATA TO AID THE ADVANCEMENT OF ITS EFFORTS TO SUSTAIN OR GAIN FUNDING TO SHARE AND RECEIVE MY PERSONAL INFORMATION AND DOCUMENTS AS IT RELATES TO MY NEED FOR SERVICE TO USE MY PERSONAL DATA AND PROFILE AS NEEDED AND OR REQUIRED BY FUNDING SOURCES.
SIGN AND DATE*

Clear
Should be Empty:

Community Support Intake Form