Skip to form

Brevard County HHS

BrevardCaresAct2020@brevardfl.gov

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

Document Signers
    • 1 Signer1

SeamlessDocs

BREVARD COUNTY CORONAVIRUS (COVID-19) BURIAL PROGRAM APPLICATION

Income Eligibility


Must be below 150% of Poverty:



All applications must be accompanied by the following documents:

  • Proof of Brevard County Residency

  • Social Security Cards for all household members

  • Birth Certificates for all children listed on the application

  • Proof of all household member's income for the 3 months prior to the date of application

  • Bank statements for all household members for the 3 months prior to the date of application

  • A copy of the Death Certificate which indicates cause is directly or indirectly related to Coronavirus (COVID-19)

FAILURE TO SUBMIT ALL REQUIRED DOCUMENTS WILL RESULT IN DENIAL


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

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

Proof of Brevard County residency (for example: Driver's License, Current Utility Bill, etc.) Click Here to Upload
Social Security Card(s) for all household members Click Here to Upload
Birth Certificates for all children under 18 listed on the application (if applicable) Click Here to Upload
Proof of all household member's income for the past 3 months from the date of the application Click Here to Upload
All bank statements for all household members for the past 3 months from the date of the application Click Here to Upload
Copy of a Death Certificate which indicates cause id directly or indirectly related to Coronavirus (COVID-19) Click Here to Upload