• CSBG Application - Chatham/Orange/Randolph

    Applicant Information
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -
  •  -
  • CSBG Application

    Household Member(s) Information
  • Complete Other Household Member(s) Information Below:

    • Other Family Member 1  
    •  -  -
      Pick a Date
    • Other Family Member 2  
    •  -  -
      Pick a Date
    • Other Family Member 3  
    •  -  -
      Pick a Date
    • Other Family Member 4  
    •  -  -
      Pick a Date
    • Other Family Member 5  
    •  -  -
      Pick a Date
  • CSBG Application

    Income Eligibility Information
  •  
  •  -  -
    Pick a Date
  • CSBG Application

    Other Information
  • 0/250
  • CSBG Application

    Background Check
  • Central Piedmont Community Action, Inc does not require a submission of your criminal background for enrollment.

    Do you have any issues in your past or present which may be a barrier to gaining employment?

  • 0/200
  • CSBG Application

    Household
  • 0/150
  • CSBG Application

    Goals
  • 0/250
  • CSBG Application

    Complete Application
  • I hereby attest that the information I have provided on this intake form and any attachments is true and accurate to the best of my knowledge. I understand that this information is subject to verification and I realize the deliberate falsification or misrepresentation may result in the rejection of my application, and may subject me to prosecution under applicable State and Federal statues. I hereby give my consent to information contained on this form to be discussed and/or released to concerned social service agencies or other entities in order to make an accurate determination of my eligibility and complete the delivery of assistance to my household. I have been notified of my right to appeal any denial of service or assistance for which I may be eligible and the procedure for appeal. By this consent, I shall hold CPCA harmless for any liability that I may incur as a result of any disclosure made with the bounds of my consent and authorization.

    This application expires in 30 days after which a new application would need to be submitted.

  •  -  -
    Pick a Date
  • Clear
  • Clear
  • Should be Empty: