Client Data Sheet (CDS)

Client Data Sheet (CDS)

BEAM
To be eligible for emergency financial assistance, food pantry, and our Single Parent or Senior programs, you must live or work in the Beaches area in one of the following zip codes 32233, 32266, 32250, 32082, 32224, 32227 or 32228 (NAS Mayport).

Active duty service members and their spouses are also eligible to visit our food pantries, regardless of their zip code.

Please contact our offices if you have any questions at 904-241-2326.
Temporarily, active duty service members and their spouses who are impacted by the government shutdown may also be eligible for financial assistance regardless of their zip codes.
Please select which zip code you live or work in.*

32082322243222732233322283225032266None of the above

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Name*

First NameLast Name
What Program Are You Interested In?*
Are you currently facing eviction or do you have final notice to leave your home?*
What is the status of your current mortgage?*
Have you received a utility shut-off or disconnection notice? *
Birthdate*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Preferred phone
Email
example@example.com
Gender
Race*
Marital Status*
Education Level
Monthly Income ($)
Are you a veteran or the spouse of a veteran?*
Are you Active-Duty military or the spouse of Active-Duty military?*
Have you or someone in your household been affected by the recent government shutdown?*

Yes, I or someone in my household is a federal employee or contractor not being paid.Yes, reduced hours or pay from an affected employerI’m worried it may affect us soonNo impact so farOther
Are you receiving disability benefits?*
Are you a single parent of a minor child?*
Are you receiving SNAP benefits?*
Total number of people in your household?*
Please upload a copy of your Photo ID (such as a Driver's license, State ID, Military ID, or Passport)

Screenshots are not permitted and all documents must be clear and readable.

Active duty military families interested in food assistance can provide military/spouse ID ONLY.
Photo ID File Upload*

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Please upload a document verifying you live or work in our service area. (such as a current signed lease or mortgage statement OR pay stubs or letter from employer).

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Please upload a at least one document as proof of income.

Screenshots and Envelopes WILL NOT BE ACCEPTED.
Photos of documents are accepted but must be legibile.

Examples of documents that will be accepted are:
- Paystubs for the past 30 days
- Social Security award letter
- Unemployment benefits statement
- Pension or retirement statement
- Child support and/or alimony documentation
- Offer letter from future employer
Proof of Income File(s) Upload

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Please upload a copy of your most recent Past Due Utility Bill. Screenshots and Envelopes WILL NOT BE ACCEPTED. Photos of documents are accepted but must be legible.*

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Please upload a copy of your Current Signed Lease. First page and signature page are all that is needed. Screenshots WILL NOT BE ACCEPTED. Photos of documents are accepted but must be legible. *

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Please upload a copy of your Current Mortgage Statement. Screenshots WILL NOT BE ACCEPTED. Photos of documents are accepted be must be legible. *

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Additional Comments and Questions
Should be Empty: