ECCO Client Eligibility Form

What services are you interested in receiving (select all that apply)?*

Personal Information

Please attach your proof of residency (most current electric or water bill, mortgage statement or rental agreement). *If the bills aren't in your name, you will need to complete ECCO's Documentation of Physical Address form (see form at bottom of page):

Date of Birth*

Please attach a copy of your current photo ID:

How many adults are in your household?*

How many minors are in your household?*

Do you have insurance (Medicaid, Medicare, or Private)? Regardless of status, all applicants must complete ECCO's Declaration of Insurance form (see form at bottom of page)*

Employment

Source of Income*

Please attach a proof of income below:

• If employed: pay stubs for the last 30 days

• If self-employed: complete ECCO’s Self-Declaration of Income form (see form at bottom of page)

• If receiving disability/social security: 2023 government award letter

• If performing an undocumented job: complete ECCO’s Statement of Income from Employer form (see form at bottom of page)

• If Unemployed: if receiving unemployment assistance/TANF/FI - provide the 2023 government award letter or paystub; If no income in the household, complete ECCO’s No Income form (see form at bottom of page)

Other Info

How did you hear about ECCO?*

Release of Information (ROI)*

The CharityTracker 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. Trident United Way administers CharityTracker on behalf of participating agencies of the CharityTracker Assistance Network, including East Cooper Community Outreach (ECCO). I understand that all information gathered about me is personal and private and that I do not have to participate in CharityTracker. I also understand that if I choose to not participate, this may limit response to my need. I have had an opportunity to ask questions about CharityTracker and to review the basic identifying information. This Release of Information will remain in effect for 3 years from the date noted on this page unless I make a formal request to ECCO that I no longer wish to participate in CharityTracker. I authorize ECCO to share my basic, identifying and non-confidential service transactions/information as needed with other organizations so as to enable the best possibilities for assistance with my need. I authorize the use of a copy of this original to serve as an original for the purposes stated above. I further authorize the exchange of this information with the following agencies and entities as necessary: landlords, utility companies, mortgage companies, St. Vincent de Paul, Operation Home, Family Services, CARES Clinic, ECCO Dental Clinic, ECCO Counseling (as seen necessary), Trident One Stop, WorkKeys, Pro Bono Law, Vocational Rehabilitation and any other agencies in the SafetyNet Network.

Client Services Agreement*

ECCO 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 that a client (or a member of the client’s household) exhibits behavior that is inconsistent with ECCO's values, ECCO has the right to temporarily suspend services for a period of time. By agreeing to this statement, I fully acknowledge that I have read and understand ECCO’s Client Services Agreement. Additionally, I understand that ECCO has the right to confirm and follow up on any and all information that is provided during the eligibility verification process. I also understand that providing false information may disqualify me and my household from receiving services. Lastly, I understand that completing the eligibility process does not guarantee access to any/all services. I am attesting that the information I have provided to ECCO on this date below is accurate and truthful.

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