The information collected in this application will help us determine your need(s) and quickly get in contact with you to process your request. The application process should take less than 5 minutes.  However, if uploading large documents, the time may be longer.  Please note that this assistance is for Charlotte County residents only.

Personal Information


Employment Information

Employment Status: Full-TimePart-TimeUnemployed


Household Information

Marital Status: SingleMarriedDivorcedWidowedNon-Married Partner

Housing Status: OwnRentOther

Any Veterans in the Household?: NoYes


Assistance Information

As a result of COVID-19, did you experience any of the following? (CHECK ALL THAT APPLY AND PUT AMOUNT DUE):
Lost wages due to employer closure, slow business, or illnessLost wages due to school/childcare closureOther financial crisis

Due to this, are you behind on any of the following? (Include past-due amount):

Rent

Mortgage

Electric

Water

Vehicle

Insurance

Childcare

Phone

Other


Need(s) Information


Support documentation

Attach up to five (5) pieces of support documentation such as paystubs showing income loss, letter from employer, copies of past due bills, etc. For Rent, please include copy of lease, W-9, and property appraiser printout. For Mortgage, please include a copy of your mortgage statement. Accepted file types include pdf, txt, jpg, jpeg, png, gif, doc, and docx and are limited to 5mb each.

Attachment 1
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Attachment 4
Attachment 5


Acceptance

Have you filled out this application already?NoYes