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COVID19 EMERGENCY ASSISTANCE PROGRAM APPLICATION

  1. INSTRUCTIONS/NOTICE

    THIS PROGRAM IS FOR CITY OF TITUSVILLE RESIDENTS ONLY. YOU MUST HAVE A COVID19 RELATED JOB LOSS OR COVID19 RELATED REDUCTION OF INCOME TO APPLY. IF YOU DO NOT MEET THESE CONDITIONS, PLEASE DO NOT APPLY FOR THIS PROGRAM. INSTEAD, PLEASE CALL 2-1-1 FOR A LIST OF OTHER AGENCIES THAT MAY BE ABLE TO ASSIST YOU.

  2. Have you received assistance or received a commitment from any other source for the requested assistance? Yes or No

  3. UNMET NEEDS:

    Here you will indicated your unmet needs in which the household is unable to sustain due to COVID19 financial impacts; up to six months

  4. Enter the amount of delinquent rent that you need assistance with, including any late fees

  5. Enter the amount due this month, including any late fees

  6. Enter an amount that is anticipated the household will not be able to pay.

  7. Enter the amount of delinquent utilities that you need assistance with

  8. Enter the amount due for this month

  9. Enter the amount of delinquent mortgage payments due

  10. Enter the amount due for this month

  11. Enter an amount that is anticipated the household will not be able to pay

  12. Applicant's name, phone number, and email address

  13. Co-Applicant's name, phone number, and email address

  14. Residence address of applicant(s)

  15. If different than physical home address, please provide

  16. HOUSEHOLD/FAMILY INFORMATION

    Please complete the following for ALL household members residing in the residence

  17. 00/00/0000

  18. 00/00/0000

  19. 00/00/0000

  20. 00/00/0000

  21. 00/00/0000

  22. 00/00/0000

  23. 00/00/0000

  24. 00/00/0000

  25. CHARACTERISTICS OF HEAD OF HOUSEHOLD MEMBER

  26. EMPLOYMENT

    Applicant's employer (current)

  27. Please indicate which of the following statements apply to the Applicant

  28. CO-APPLICANT'S EMPLOYER (CURRENT)

  29. Please indicate which of the following statements apply to the Co-Applicant:

  30. HOUSEHOLD INCOME:

    Please indicate an amount and if you are paid weekly (W), bi-weekly (BW), bi-monthly (BM), monthly (M), or annually (A)

  31. APPLICANT

  32. Indicate if (W), (BW), (BM), (M), or (A)

  33. If not applicable, enter 0

  34. If not applicable, enter 0 Do not enter your social security number

  35. If not applicable, enter 0

  36. If not applicable, enter 0

  37. If not applicable, enter 0

  38. If not applicable, enter 0

  39. If not applicable, enter 0

  40. If not applicable, enter 0

  41. If not applicable, enter 0

  42. CO- APPLICANT

  43. If not applicable, enter 0

  44. If not applicable, enter 0 Do not enter your social security number

  45. If not applicable, enter 0

  46. If not applicable, enter 0

  47. If not applicable, enter 0

  48. If not applicable, enter 0

  49. If not applicable, enter 0

  50. If not applicable, enter 0

  51. If not applicable, enter 0

  52. HOUSEHOLD ASSETS

    Please enter the asset value for all assets

  53. APPLICANT

  54. Enter account balance. If not applicable, enter NA. Do not enter your checking account number

  55. Enter account balance. If not applicable, enter NA. Do not enter your account number

  56. Enter account balance. If not applicable, enter NA. Do not enter your card or account number

  57. Un-liquidated Assets

    Enter cash value and income from assets. Do not enter account numbers

  58. CO-APPLICANT OR OTHER ADULT

  59. Enter account balance. If not applicable, enter NA. Do not enter account number

  60. Enter account balance. If not applicable, enter NA. Do not enter account number

  61. Enter account balance. If not applicable, enter NA. Do not enter account number

  62. Un-liquidated Assets

    Enter cash value and income from assets. Do not enter account numbers

  63. HOUSEHOLD LIABILITIES

  64. Answer "Yes" or "No." If you have answered yes, please list the agency and describe the requested assistance.

  65. If Yes, please list from whom and describe the amount of assistance (per month) and the purpose of the assistance

  66. ATTACHMENTS

    The following information is required with your application:

  67. Attached notice or statement from employer

  68. In addition to your statement from your employer, upload proof of filing for unemployment benefits or benefit statement

  69. Links to each of the following required forms is provided below

  70. Attach completed form

  71. Attach completed form

  72. Attach completed form

  73. Attach completed form

  74. Attach completed form

  75. Upload copy of current lease agreement with landlord

  76. Upload delinquent rent notice

  77. Upload delinquent FPL bills

  78. Upload other delinquent utility bill. NOTE- City water bill is not eligible for assistance

  79. Upload mortgage statement

  80. If you have received a forbearance on your mortgage, upload agreement

  81. NOTICE

    Applicant is responsible for supplying all required documents with application submittal. Copying service is not provided.

  82. WARNING

    Failure to provide all required documents will delay assistance and may result in the denial of your application.

  83. WARNING FALSE INFORMATION

    Florida Statute 817 provides that willful false statements or misrepresentation concerning income and assets or liabilities relating to financial condition is a misdemeanor of the first-degree and is punishable by fines and imprisonment provided under S 775.082 or 775.83.

  84. Attest

    The information provided in this application is true and complete to the best of my/our knowledge and belief. I/We consent to the disclosure of such information for the purpose of income verification related to my/our application for financial assistance. I/We understand that any willful misstatement of material facts will be grounds for disqualification. I/We understand that the information provided is needed to determine eligibility and in no way assures qualification for assistance. I/We also agree to provide any other documentation necessary to verify my/our eligibility.

  85. APPLICANT Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  86. CO-APPLICANT Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  87. OTHER ADULT MEMBER Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

  88. **NOTICE**

    There will be additional documentation required from you. The City will communicate with you via the email address provided to request this documentation, so please check your email periodically, including your spam box, to avoid delays.

  89. Leave This Blank:

  90. This field is not part of the form submission.