Financial Assistance Form

Be sure to fill out all the required fields for this application to be submitted successfully.

Once the form is submitted, an ECCO staff member will follow up within 5 business days using the contact information you provide below. Please feel free to call us at (843) 849-9220 with any questions or concerns. Thanks!

Financial Assistance Form

Are you a current client of ECCO?(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Date of Birth(Required)

What bill are you seeking assistance with?(Required)

Electric

Water

Rent

Mortgage

Other

Estimated amount of bill?(Required)

How much can you contribute towards the bill?(Required)

Please attach the bill you are seeking assistance with:

Drop files here or

Max. file size: 50 MB.

Which of the following unforeseen hardships best describes what has caused you to apply for financial assistance?(Required)

Unusual Increase in Expenses

Loss of Income

Unexpected Expense

Other

If available, please attach documents/files that support your request for assistance (receipt from unexpected expense, loss of income from employer, etc.):

Drop files here or

Max. file size: 50 MB.

Financial Assistance Form

Financial Assistance Form

Thank you for subscribing to our mailing list. Connect with us on social to stay up-to-date on everything happening at ECCO!