Family Assistance Request (Online)

Financial assistance request form

Please NOTE: We are ONLY able to assist families in East Volusia County and Flagler County. We are ONLY able to assist families with minor children, age 17 or younger. Being enrolled in our mentor program is a requirement for our limited financial assistance.

Date

How did you hear about Salty Family Services?

Contact Information

Please NOTE: We are ONLY able assist families with minor children, age 17 or younger.

Do you have legal custody of minor child(ren)?

Please select one option.

Yes No

Name of Parent/Guardian:

Phone

Birth Date

Please NOTE: We are ONLY able to serve families in East Volusia (East of I-95) and Flagler counties.

Address

How many minor children are living with you?

Please select one option.

1 2 3 4 5 6 7 8 9 10 or more

Provide ages of your children:

Is there anyone else 18 or older living in the home? If so, please provide name and date of birth.

Marital Status:

Please select one option.

Single Married In a Relationship Widowed Divorced Separated

Do you have a DCF investigator working with you?

Please select all that apply.

Yes No

If so, who is your DCF Investigator?

Assistance Details

Please NOTE: We are unable to assist with hotel stays, car repairs or insurance.

Main type of assistance requested?

Please select one option.

Utility Bill Rent Mortgage Other

Please provide details on the type of assistance you are requesting, including amounts owed.

Are you employed

Please select one option.

Yes No

If employed then full time or part time?

Please select one option.

Full Time Part Time Not Employed

If so, where are you employed?

Description

Financial assistance request form

Family Assistance Request (Online)

Description

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