Financial Assistance Form

Please make 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!

    Are you an ECCO client?*

    Have you ever visited ECCO before?*

    Which of the following best describes what has caused you to apply for financial assistance?"*

    Personal Information

    Date of Birth*

    Please list your cell phone provider here, if you give us consent to contact you via text.

    How many adults are in your household?*

    How many minors are in your household?*

    What bill are you seeking assistance with?*

    If you selected other, please explain what bill you're seeking assistance with?

    What is the estimated amount of the bill you are seeking assistance with?*

    What amount can you contribute towards the bill you are seeking assistance with?*

    To receive financial assistance, eligible clients are required to provide 1) Phone ID for all adults in the household, 2) the most recent bill that you're requesting assistance with, and 3) one of the following items:

    Pay stubs showing loss of income in the past 60 days

    Past and present utility bills showing the increase bills in the past 45 days

    Receipts showing the unforeseen medical or repair bill in the past 45 days

    Letter from an employer with the last day of work/or verification of termination or an unemployment benefits letter

    Employment

    Source of Income*

    Last date of employment, if not currently employed or loss of job.

    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, Marie Carter & Associates (as seen necessary), Trident One Stop, WorkKeys, Pro Bono Law, Vocational Rehabilitation and any other agencies in the SafetyNet Network.

    Today's Date*