Mid Florida Community Services, Inc. Community Services Application for Assistance

Please NOTE before submitting this application, be prepared to upload the following documents:
(*Note: these documents are required to determine eligibility for assistance.)
-*Photo ID
-*Social Security Cards
-*Income Information
-*Electric Bill (all pages and for each month requesting assistance)
-Food Stamp award/denial letter
Education Level *
0/20 characters
Food Stamps:
Housing Status *
Public Housing (section 8, HUD, Low Income/USDA) *
Does anyone in your household live in a dormitory, nursing home, adult foster home, or any kind of group living facility?
Are any household members: (select all that apply) *
Was client referred to the local Veteran's Affairs office?
Are you or any member of your household a member of the Poarch Creek Indian Tribe?
Your primary source of energy. *
Provide the following information about the primary source of energy you use to cool or heat your home.
If you, or any member of your household, has received energy assistance in the current season, complete the information below:
 Name of AgencyType of Help (elderly, crisis)Date
WAP REFERRAL: If the applicant is a homeowner, has he/she received more than three LIHEAP or EHEAEP benefit in the last 18 months?
If the answer to the previous question is 'yes', was the applicant referred to WAP?
Are you, any member of your family, or any of your household members an employee of Mid Florida Community Services, Inc.? *
Fraud Statement: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need, i.e., those households in which the elderly, disabled, medically needy, or children under the age of 5 reside. I authorize the agency to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if I am applying for crisis assistance, the agency has 48 hours; 18 hours if my situation is life threatening, to approve or deny my application, and, if I am applying for Home Energy Assistance, the agency has 45 days to approve or deny my application. I am also aware that if I am not approved or denied within the time allowed, or not apprvoed for the correct amount, I have a right to an appeals hearing.
Acceptance of Application to Mid Florida Community Services, Inc.: I certify that the guidelines have been explained to me and that I waive the provisions for the privacy act to allow MFCS to verify income eligibility. I further certify that all information on this application is true and correct.
Applicant Signature *
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