Financial Assistance Form

First Name

Last Name

Email

Todays Date

Address

City

State

Zip

Phone

Date of Birth

Employer

Name(s) and Age(s) of Children Living at this Address:

Marital Status

Name(s) and Age(s) of Other Adults Living at this Address:

Total Monthly Expenses (Rent/Mortgage, Electric, Water, Car, Insurance, Phone, etc):

What is the Reason for your Request?

How do you Plan to Pay this Bill & Others in the Future?

I Have Read the Information Release.

yes

Supporting Documents (Past Due Statement/Invoice, Driver License, etc)

Send

INFORMATION RELEASE

THE COMMUNITY SERVICES ORGANIZATION ASSISTANCE NETWORK, HEREINAFTER REFERRED TO AS ‘CHARITYTRACKER’, IS A SHARED, COMPUTERIZED RECORD KEEPING SYSTEM THAT CAPTURES
INFORMATION ABOUT PEOPLE EXPERIENCING NEED FOR EMERGENCY SERVICES, INCLUDING BUT NOT LIMITED TO ASSISTANCE WITH UTILITY BILLS, MEDICATIONS, RENT/MORTGAGE PAYMENTS, ETC.
BEAUFORT COUNTY HUMAN SERVICES ALLIANCE (ADMINISTRATING AGENCY) ADMINISTERS CHARITYTRACKER ON BEHALF OF PARTICIPATING AGENCIES OF THE CHARITYTRACKER ASSISTANCE NETWORK, INCLUDING HELP OF BEAUFORT (PARTICIPATING AGENCY).
I UNDERSTAND THAT ALL INFORMATION GATHERED ABOUT ME IS PERSONAL AND PRIVATE AND THAT I DO NOT HAVE TO PARTICIPATE IN CHARITYTRACKER. I HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS
ABOUT CHARITYTRACKER AND TO REVIEW THE BASIC IDENTIFYING INFORMATION, WHICH IS AUTHORIZED BY THIS RELEASE FOR THE CHARITYTRACKER ASSISTANCE NETWORK PARTICIPATING
AGENCIES TO SHARE. I ALSO UNDERSTAND THAT INFORMATION ABOUT NON-CONFIDENTIAL SERVICES PROVIDED TO ME BY CHARITYTRACKER PARTICIPATING AGENCIES MAY BE SHARED WITH OTHER
CHARITYTRACKER PARTICIPATING AGENCIES.
THIS RELEASE OF INFORMATION WILL REMAIN IN EFFECT
FOR 3 YEARS FROM THE DATE NOTED UNDER MY SIGNATURE AT THE BOTTOM OF THIS PAGE UNLESS I MAKE A FORMAL REQUEST TO THIS ORGANIZATION THAT I NO LONGER WISH TO PARTICIPATE IN
CHARITYTRACKER.

I AUTHORIZE HELP OF BEAUFORT, AS A CHARITYTRACKER PARTICIPATING AGENCY, TO SHARE MY BASIC, IDENTIFYING AND NON-CONFIDENTIAL SERVICE TRANSACTIONS/INFORMATION WITH OTHER
CHARITYTRACKER PARTICIPATING AGENCIES. I AUTHORIZE THE USE OF A COPY OF THIS ORIGINAL TO SERVE AS AN ORIGINAL FOR THE PURPOSES STATED ABOVE. I FURTHER AUTHORIZE HELP OF BEAUFORT (PARTICIPATING AGENCY), AS A CHARITYTRACKER PARTICIPATING AGENCY, TO SHARE MY
DEPENDENT’S BASIC, IDENTIFYING AND NON-CONFIDENTIAL SERVICE TRANSACTIONS/INFORMATION WITH OTHER CHARITYTRACKER PARTICIPATING AGENCIES.