ECCO Client Eligibility Form

Receiving services at ECCO begins by completing our Client Eligibility form. Once you’ve submitted the form, an ECCO staff member will follow up within 3 business days using the contact information you provide below. All individuals that receive services at ECCO must complete our client eligibility process annually if living in our service area (or every six months if working in our service area).If supporting documents are not turned in within 30 days of application, the request will be discarded.

Please make sure to fill out all required fields for this application to be submitted successfully.

Questions? Or unable to attach the required documents? Please call (843) 849-9220 to speak with an ECCO representative.

    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)*


    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)*

    Client Services Agreement*

    ECCO’s Supplemental Forms for Client Eligibility:

    (Click on each form below to open and download)