Camden County Council On Economic Opportunity, Inc.
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Executive Director
Board President
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Employment Training
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Individual Development Account (IDA) Program
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Online Screening Form
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Indicates required field
Name
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First
Last
Street Address
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City
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Zip Code
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County
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Phone Number
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Alternate Phone Number
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Email
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Social Security Number (last 4 digits)
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Type of Assistance Needed (Check all being requested.)
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Back Rent
Relocation
Utility
Mortgage
Food
Have you ever applied for Mortgage, Rent, Food (SNAP) or Utility Assistance in the past 12 months?
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Yes
No
If Yes, did you receive assistance? What type and through which agency?
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Are you currently receiving or on a waiting list for any type of assistance through another agency?
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Yes
No
If Yes, please explain:
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What is the source of income in the household? (Check all that apply.)
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Wages/Employment
SSI
SSA
SSDI
Unemployment benefits
Workman's Compensation
Child Support
TANF/GA (Cash benefits)
Long-term Disability
VA Benefits
Short-term Disability
Other
Gross Monthly Household Income
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# of people in the household
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What caused your crisis? (Check all that apply.)
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Medical Emergency
Loss of Income
COVID-19
Crime
Eviction
Domestic Violence
Natural Disaster (Flood, Fire, etc.)
Homeless
Other
If Other, please explain:
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Answer the following questions if you are applying for Utility Assistance?
What is the amount that you owe?
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Do you have any money saved towards the amount owed?
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Yes
No
If Yes, How much?
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Have you attempted a payment arrangement with your utility company?
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Yes
No
Answer the following questions if you are applying for Back Rent Assistance OR Mortgage?
How much is your monthly rent OR mortgage?
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Are you living in Subsidized or Section 8 housing?
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Yes
No
Do you have a Court Summons with a Docket # on it?
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Yes
No
If Yes, what it the Docket #?
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When is the court date?
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If No, did you receive a late notice or intent to file an eviction?
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Yes
No
Answer the following questions if you are applying for Relocation Assistance?
Are you currently homeless/displaced (residing in an uninhabitable place, shelter or motel) OR evicted within the past 6 months?
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Were you issued a Warrant of Removal or a Notice of Ejection/Eviction?
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Yes
No
If Yes, when did this occur?
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Have you located a potential unit reside in?
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Yes
No
If Yes, when is it available?
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What is the amount of the security deposit requested?
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How much is the monthly rent?
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ALL APPLICANTS REQUESTING ASSISTANCE MUST COMPLETE THE SECTION BELOW. (Please list everyone in the household.)
Name
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First
Last
Date of Birth
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Relation to applicant
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Gender
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Monthly Income Amount
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Source of Income
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Name
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First
Last
Date of Birth
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Relation to applicant
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Gender
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Monthly Income Amount
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Source of Income
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Name
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First
Last
Date of Birth
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Relation to applicant
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Gender
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Monthly Income Amount
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Source of Income
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Name
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First
Last
Date of Birth
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Relation to applicant
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Gender
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Monthly Income Amount
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Source of Income
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Name
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First
Last
Date of Birth
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Relation to applicant
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Gender
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Monthly Income Amount
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Source of Income
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Please check the entire form to make sure each section is correct. Then click the "Submit" button below. A Case Manager will contact you within 1 business day. Thank you.
Submit