Family Assistance Request (Online)

Please complete this form to request assistance. A member of our team will get back to you within 3-4 business days.

Please NOTE: 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.

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

*

Please select one option.

Yes No

Name of Parent/Guardian:

*

Phone

*

Date of Birth

*

Email

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.

*

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?

*

Description

Please complete this form to request assistance. A member of our team will get back to you within 3-4 business days.

Please Fix the Following

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