COVID-19 Assistance Application Please complete all of the information below to apply for assistance from the COVID-19 Support Fund. Applications will be reviewed by our partners at S.A.F.E., Inc. Additional information may be required to process your request. Submitting this application is not a guarantee that you will receive assistance. Thank you! Step 1 of 2 50% If you need to apply by phone, please call: Chickasaw County residents, call Excel, Inc. at 662-447-2030 Other counties, call S.A.F.E., Inc. at 662-841-9138. Before starting the application, please gather the following documentation that you will need to scan and upload into this form: Your photo ID Social Security cards for all members of your household The bill with which you need assistance (utility or rent statement) Proof of income for the past 30 days, including pay stubs, SNAP benefits, child support, TANF, disability, unemployment, etc. If someone else pays your bills, you must provide a statement of how long they have been paying your bills and the amount they provide. If you are unemployed, you must provide proof that you have been seeking employment, have applied for disability, or explain the reason you cannot work. Eligibility for AssistancePlease check all that apply to determine your eligibility:* I was employed prior to the COVID-19 outbreak and was laid off or had my hours significantly reduced. I contracted COVID-19 or am the caretaker of someone who did. I am at high risk for COVID-19 due to a pre-existing medical condition and am unable to work, or I am the caretaker of someone at high risk. I have children under 18 in my household. I am 65 or older. None of the above apply to me. In which county do you live?*AlcornBentonCalhounChickasawClayItawambaLafayetteLeeLowndesMarshallMonroeOktibbehaPontotocPrentissTippahTishomingoUnionNone of the above. Personal InformationPlease answer these questions for yourself or the person requesting the assistance.Name* First Last Spouse/Partner Name, if applicable First Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone*Spouse/Partner Phone, if applicableEmail Date of Birth* Date Format: MM slash DD slash YYYY Age*Gender*MaleFemaleOther/Prefer not to sayRace or EthnicityAsian/Pacific IslandAfrican-American/BlackCaucasian/WhiteHispanic/LatinoNative AmericanMore than one raceOther/Prefer not to sayMarital Status*SingleMarriedLiving with PartnerSeparated/DivorcedWidowedOtherHighest Education Level*Less than high schoolHigh School DiplomaSome college, no degreeAssociate's DegreeBachelor's DegreeMaster's or Professional DegreeDoctorateAre you a veteran or a member of the armed forces?*I have never served in the armed forces.Currently serving in the armed forcesVeteranHousehold InformationHow many adults reside in your household?*12345 or moreHow many children under the age of 18 reside in your household?*123456 or moreAre you currently employed?*YesNoEmployerWhat is your total annual household income from all sources?*What is the source(s) of your household income?*Does anyone in your household receive any of the following?*Please check all that apply. TANF (Temporary Aid for Needy Families, aka cash assistance) SNAP (Supplemental Nutrition Assistance Program, aka food stamps) DHS Daycare Assistance Does anyone in your household have the following types of health insurance?*Please check all that apply. Medicaid CHIP Medicare Employer-Provided Insurance Private Insurance DocumentationPlease provide a copy of your photo ID.* Drop files here or Please provide Social Security cards for all members of your household.* Drop files here or Please provide a statement for the bill with which you are requesting assistance (i.e., utility bill or rent statement).* Drop files here or Please provide proof of all household income for the past 30 days.* Drop files here or If you are unemployed, please provide proof of job search, application for disability, or the reason you cannot work. Drop files here or ConfirmationConsent and Confirmation*I certify that all information provided in this application is true and complete to the best of my knowledge. Checking this box serves as my electronic signature and consent to use this information to determine my eligibility for assistance. I agree.