Client Forms
When walking through ECCO’s Client Eligibility process, local neighbors will need to complete a few forms to verify they live/work within our service area, state insurance and income status, and more. Below, you’ll find links to each of the needed forms, in PDF format. If you have any questions about any of the forms below, please call us at 843-849-9220 or reach us by email at givehope@eccocharleston.org.
Accordian
ECCO's ROI Form
Click here to download ECCO’s Custom Release of Information form.
This form acknowledges that you, as a client, give ECCO permission to add the information you provide to CharityTracker – a shared, computerized record-keeping system that contains information about people experiencing a need for basic needs services and financial stability services, including but not limited to assistance with utility bills, medications, rent/mortgage payments, etc. Trident United Way administers CharityTracker on behalf of participating agencies in Berkeley, Charleston, and Dorchester counties including ECCO.
Client Services Agreement
East Cooper Community Outreach staff, volunteers, partners, and students take pride in providing our services with compassion, collaboration, respect, and integrity. We strive to consistently demonstrate these core values. Clients are also asked to demonstrate the same values when interacting with members of the ECCO team. In the unlikely event, a client’s behavior is inconsistent with ECCO’s values, ECCO has the right to temporarily suspend services for a period of time. By signing this document, you acknowledge that you have read and understand ECCO’s Client Services Agreement.
Click here to download the Client Services Agreement
Documentation of Physical Address Form
All ECCO services are available to those who live and work East of the Cooper River, with multiple services also available to neighbors living in the Tri-County communities. However, to begin the client eligibility process, we need to make sure you live within our service area.
Click here to download our Documentation of Physical Address Form
Declaration of Insurance Status Form
ECCO provides a range of dental procedures and services, medical clinics, and prescription assistance programs for uninsured adults each year – all at no cost to the patient. To apply for these programs, you’ll need to complete this form:
Click here to download the Declaration of Insurance Status Form
Statement of Income from Employer Form
This form is to be used if you cannot provide pay stubs and MUST be completed by your employer. As a reminder, this is for ECCO use only and we are not a government entity. The use of this information is for the sole purpose of verifying your income.
Click here to download the Statement of Income from Employer Form
No Income Form
This form is to be used only if you are not receiving any income at this time. As a reminder, this is for ECCO use only and the use of this information is for the sole purpose of verifying your income.
Self-Declaration of Income Form
All ECCO clients must be qualified by their income level – which is based on 250% of the Federal Poverty Guidelines. Click here to review the full chart of those guidelines.
Click here to download the Self-Declaration of Income Form
If your employer doesn’t provide paystubs, please click the next tab to complete the Statement of Income from Employer Form.