INTAKE FORM
IN RESPONSE TO HURRICANE HELENE, CFCAA IS OFFERING LIMITED DISASTER RELIEF ASSISTANCE TO ELIGIBLE HOUSEHOLDS. PLEASE COMPLETE THE FORM BELOW TO REQUEST ASSISTANCE. FORM COMPLETION IS NOT A GUARANTEE OF ASSISTANCE. APPLICANTS MUST RESIDE IN ALACHUA, LEVY, OR MARION COUNTY.
Applicant Name
*
First Name
Last Name
Residential Address
*
Street Address
Street Address Line 2
City
State
Zip Code
What county do you live in?
*
Alachua County
Levy County
Marion County
Contact Number
*
Email
*
example@example.com
Back
Next
How Many People In Household?
*
Anyone in the Household:
*
60 years old or older
Disabled
5 years old or under
NONE OF THE ABOVE
Anyone in the Household a Veteran?
*
YES
NO
Back
Next
What is the monthly gross income of the Household?
*
Household Demographics - List All Household Members and complete each column (11 total)
*
Does any Household member have a disability and receive disability benefits?
*
YES
NO
Does any Household member receive child support payment(s)?
*
YES
NO
Please check all other government assistance received by your household.
*
NONE - My household does not receive any other government assistance
SNAP (Food Stamps)
TANF (cash)
WIC
School Food
Medicaid
VA
EHEAP
Other
Back
Next
PLEASE BE ADVISED:
FUNDS MAY PROVIDE ASSISTANCE FOR RECONNECTING HOME POWER, INCLUDING UTILITY DEPOSITS AND LATE FEES, AS WELL AS COVERING TEMPORARY HOUSING COSTS. ADDITIONALLY, ASSISTANCE MAY BE AVAILABLE FOR THE PURCHASE OF GENERATORS AND FUEL, REPAIR OF ELECTRICAL WIRING OR GAS LINES, REPLACEMENT OF UTILITY BOXES, AND INSTALLATION OR REPAIR OF AIR CONDITIONING AND HEATING SYSTEMS. ALL ASSISTANCE MUST BE ENERGY-RELATED AND CONNECTED TO DISASTER-RELATED EXPENDITURES INCURRED DURING THE DECLARED DISASTER EVENT.
Was your household impacted by Hurricane Helene?
*
YES
NO
Describe how the disaster impacted your household:
*
Did your household experience a loss of power due to Hurricane Helene?
*
YES
NO
If yes, when did the loss occur?
*
What type of assistance are you requesting? (Select all that apply)
*
Reconnection of home power due to storm
Temporary housing costs
Purchase of generator and fuel
Repair/inspection of electrical wiring or gas line
Replacement of utility box
Installation or repair of air conditioning/heating system
Do you have proof of energy-related costs associated with the disaster?
*
YES
NO
Please describe the documentation you can provide (e.g., invoices, receipts, proposals, photos, etc.):
*
Take a Photo of Your Support Documentation
Back
Next
DISCLAIMER:
Form completion is not a guarantee of assistance. By signing below you are certifying that the information provided is true and correct.
Signature
*
Submit Intake Form
Should be Empty: