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Eligibility Form

Eligibility Form

This form helps us understand your needs and determine how we can best support you.
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    Because SEA has limited funds and serves many households in Shelby County, we must follow specific eligibility criteria when providing assistance. These guidelines help ensure that support is given in a fair and consistent way. The information you share on this form helps our team determine whether you qualify for assistance and what resources may be available to help you. 

     

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    This might include a loss of income, a medical diagnosis or hospital stay, an unexpected necessary expense, or something else.
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    We will assess for all services, but please select the one that is most urgent to you at this time.
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    • Housing
    • Utilities
    • Medical
    • Food or Diapers
    • Information
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    Please include yourself in the total
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    Homelessness may include staying in a shelter, vehicle, motel paid for by an agency, or living in a place that is not safe for or meant for people to live in.
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    Please type in a dollar amount
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    Thank you for reaching out to SEA.


    Based on the information provided, we are unable to offer assistance at this time. We know this can be disappointing, and we want you to know that your situation matters.

    Help may still be available through other community resources. We encourage you to contact United Way’s 211 Helpline by dialing 211 or visiting 211.org for help finding support.

    For other food assistance resources click here.

    If your circumstances change, you are welcome to reach out to SEA again.

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    Based on your responses you may be eligible for assistance. 

    A social worker will contact you to complete the next steps, after you sign and submit this form.

    We carefully review every request and typically assist clients in the order they are received. When a situation involves an immediate or serious crisis, we may prioritize that case to help ensure those facing the most urgent circumstances receive timely support.

    To explore other community resources, you can reach United Way’s 211 Helpline by dialing 211 or visiting 211.org.

     

     

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    Confidentiality Statement I understand that Shelby Emergency Assistance, Inc (SEA) respects the clients rights to privacy and confidentiality. Confidentiality of information will be maintained except in situations in which the client has provided consent for the release of information or the disclosure of information is required by the law. Client Agreement I understand that I will be asked to provide documentation regarding my household income, expenses, and the crisis situation. It is expected that the information I provide will be truthful and accurate. I give SEA permission to verify all information or documentation I provide. If it is found that information I provided to SEA has been falsified, I will no longer be eligible for assistance from SEA.  By signing, I affirm that I have read and agree to the above statement. 
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