Skip to form

Brevard County HHS

BrevardCaresAct2020@brevardfl.gov

2725 Judge Fran Jamieson Way, B-103, Viera, FL, 32940, US

Document Signers
    • 1 Applicant Signature

SeamlessDocs

Thank you for your interest in Brevard County Community Action Agency Community Services Block Grant Family Self Sufficiency Program.

All ITEMS LISTED ARE NEEDED TO DETERMINE ELIGIBILITY FOR EMERGENCY SERVICES AND YOU MUST HAVE ALL DOCUMENTS AT TIME OF APPLICATION.

1. YOU MUST PROVIDE TWO OF THE FOLLOWING ITEMS AS PROOF OF INTENT TO RESIDE IN BREVARD COUNTY: (bring with you)
  • a. State of Florida Drivers License or Florida Identification Card for all adult household members with a Brevard County address. AND
  • b. Proof of Employment or 2 current consecutive months (in your name) utility bills or voter registration or yearly lease on rental unit.
2. ORIGINAL SOCIAL SECURITY CARDS FOR ALL HOUSEHOLD MEMBERS.

3. BIRTH CERTIFICATES FOR ALL OF THE CHILDREN THAT ARE LISTED ON THE APPLICATION.

4. PROOF OF ALL HOUSEHOLD MEMBERS INCOME FOR THE PAST THREE MONTHS: Paycheck stubs, Unemployment Compensation payment history, Veteran’s check, Child Support payment history, AFDC/TANF, Social Security Income, Social Security Disability, Pension, Alimony, Annuity, Retirement, Workman’s Comp, Utility Allowance Reimbursement, or statement from employer stating gross and net income. If you are receiving Unemployment Compensation Benefits you will need to call 1-800-204-2418 for a payment history. A Self Declaration Form must be completed by all adult household members that have zero income or self-employment.

5. ALL RECENT BANK STATEMENTS FOR THE PAST THREE MONTHS: For all household members: Savings account, Checking account, or CD’s. (The Bank Statements must be within 1 week of the application.)

6. PROOF OF ALL MONTHLY BILLS AND EXPENSES FOR THE PAST THREE MONTHS: You must also provide receipts for payments of those bills/expenses. (Rent, electric, water, phone, gas, cable, car payments, insurance payments, furniture payments, prescriptions, child care, etc.)

7. IF YOU ARE LIVING WITH SOMEONE ELSE: You must provide a statement from them explaining your living arrangements and your financial obligations.

8. IF UNEMPLOYED: If you are not involved in the Wages program, you must be actively seeking employment. You must be registered at CareerSource Brevard and bring 2 job referrals.

9. IF YOU ARE UNABLE TO WORK: If it is due to disability or injury, you will be required to provide a statement from your physician.

Mortgage/Rental Assistance – For mortgage assistance, you must have a current statement from the mortgage company showing the amount that is due. For rental assistance, you must have a current yearly lease, HUD Form 50059 from Subsidized Housing, Rent Voucher Worksheet Form from Section 8, Rent Adjustment Notice Form from Public Housing, and a statement from the landlord showing the amount that is due.

Utilities (electric, water, or gas) – For utilities assistance, you must have utility bill.

Please note that incomplete applications will not be accepted. You must have all documents.

If you have any questions, or we can be of any assistance, please feel free to contact our office at (321) 633-1951.
Please check that you agree before continuing.
By continuing I agree that I am willing to complete a digital version of the document(s) and that information about my user session will be stored.
Signature HereClick to Sign
Signature HereClick to Sign
08/03/2021Click to Sign
Signature HereClick to Sign
08/03/2021Click to Sign

Create Your Signature

Please fill in your name and email and then either draw or type your signature below.

x

Signature Type

Type Draw Upload Custom
Clear Signature

Signature will be applied to the page. You will have a chance to review after signing.

Check this box to continue

x

Additional Signatures Required

Social Security Cards Click Here to Upload
Recent Bank Statements Click Here to Upload
Monthly Bills and Expenses Click Here to Upload
Statement of Living Arrangements and your financial obligations Click Here to Upload
Mortgage/Rental Assistance – For mortgage assistance, you must have a current statement from the mortgage company showing the amount that is due. For rental assistance, you must have a current yearly lease, HUD Form 50059 from Subsidized Housing, Rent Voucher Worksheet Form from Section 8, Rent Adjustment Notice Form from Public Housing, and a statement from the landlord showing the amount that is due. Click Here to Upload