Online Intake Application

Charlotte Area Fund, Inc.

For eligibility consideration and to receive CAF services, this application must be completed in full. Once complete,
please click “submit” and a CAF Intake Specialist will follow-up with you within 24-hours. Items to complete the identity verification; proof of residency and income should be uploaded. These documents may also be emailed to application@charlotteareafund.org.
(please be sure to include your name in the subject of your email.)

If you have any questions or need assistance completing this application please give a call at (704) 372-3010 or email application@charlotteareafund.org.

For application consideration, all of the below items must be submitted. If for any reason you cannot produce the following items, please give us a call at (704) 372-3010 or email info@charlotteareafund.org and we will assist you with the application process.

1. Identity Verification:
( Valid picture ID for each adult household member )

2. Proof of Mecklenburg County Residency:
( Utility bill, electric bill, etc. )

3. Proof of income verification for the last 90 days:
( For all household members related by marriage, birth or adoption, listed on the application at least 18 years of age or older: Completed Tax Returns OR copies of consecutive pay stubs for the past 90 days )

4. Social Security Number
(Picture of the card if possible)


General Application For Services

MF


Please Check All That Apply





Family / Household Members

*Needed for all household members related by marriage, birth or adoption, listed on the application at least 18 years of age or older:

Name DOB Relationship To Client Last 4 Digits of SS# Income Amt/Period Source
Applicant

Household Source of Income and
Monthly Amount :


$per
$per
$per
$per
$per
$per
$per
$per
$per
$per

$






Employment Information: Circle All That Apply


Employment History(most recent) : Please attach a resume if available

1.
2.
3.
4.
5.




CAF General Application For Services

Upload - Identity Verification: Valid picture ID for each adult household member
Upload - Proof of Mecklenburg County Residency: Utility bill, electric bill, etc.
Upload - Proof of income verification for the last 90 days*
(ex. Completed Tax Returns OR copies of consecutive pay stubs for the past 90 days)






Self-Declaration Of Income

I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE, THE TOTAL INCOME FOR MY

FAMILY/HOUSEHOLD WAS $

AND DID NOT EXCEED $ FOR THE PAST 12 MONTHS.


CERTIFICATION AND WAIVER OF PRIVACY RIGHTS STATEMENT

I further certify that all information provided herein is true to the best of my knowledge. I am aware that this information is subject to review and verification and I may have to provide documents to support it. I am aware that I may be denied assistance if I am found ineligible. I am aware that I may be prosecuted if I have knowingly given false information in order to receive assistance. I have been notified of my right to appeal any denial of service or assistance for which I may be eligible, and the procedure for appeal.

I allow release of information contained herein for purposes of verification.

Statement of Eligibility

Persons who apply to the Charlotte Area Fund, Inc. for services must be at or below income limits set for each program.

Procedures For Requesting An Appeal If You Are Denied Services

  1. If for any reason a customer/client is denied services, a written notice must be sent to the customer/client within 10 days from the date of the denial. The written notice will include reasons for denial of assistance, the opportunity to submit additional written information that may favorably determine eligibility, and the deadline for submitting such information. Where feasible, the CAF staff member and supervisor should speak with the individual to provide further explanation of the reasons for denial.
  2. If not satisfied with the explanation provided, the customer/client may appeal the decision by submitting a written appeal and support documents within 7 days to the following address:
    Programs Director
    Charlotte Area Fund, Inc.
    PO Box 34188
    Charlotte, NC 28234-4188

    The customer/client may request a hearing to provide additional information for re-evaluation of the individual’s eligibility determination. The hearing will be held within 7 days of the written request to the agency. Prior to the hearing or at the time of the hearing, the customer/client should provide additional information for the over - rule of the denial.
  3. Once the new/updated information is received and reviewed by the Programs Director, the customer/client will be notified in writing within 7 days after the hearing of the appeal decision regarding the eligibility status for the service previously denied.
  4. If the customer/client is not satisfied with the Programs Director’s decision, the customer/client may appeal the verdict by submitting a written appeal and support documents within 7 days of receipt of the Programs Director’s decision to the Executive Director at the above address. The Executive Director will review the information and notify the customer/client within 7 days after receipt of the information of the appeal decision regarding the eligibility status for the service previously denied.
  5. If the customer/client is dissatisfied with the decision of the Executive Director, the customer/client may submit a final written request for an appeal within 7 days of receipt of the Executive Director’s verdict to the Charlotte Area Fund, Inc. Board of Directors for a decision regarding the denied services. The Board of Directors will review the information and notify the customer/client within 14 business days after receipt of the information of their appeal decision regarding the eligibility status for the service previously denied. The Board of Directors’ decision is final.