| Resume a previously saved form
Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Password must contain the following:
  • 12 Characters
  • 1 Uppercase letter
  • 1 Lowercase letter
  • 1 Number
  • 1 Special character
Please select your language.

Welcome!


Before we get started, you will need to gather a few things. To complete this form, you’ll need to have photos or scanned copies of the following available to upload:

  • Picture ID of person applying for financial assistance.
  • Social Security documentation for all household members: Social Security (SS) card, documentation from the SS Administration, W2 form from an employer, paystub with a complete SS number, or W7 if applicable. If you or another member of your household are not registered with the SS Administration, you must provide some form of ID.
  • Proof of household income over the past 30 days, including all paystubs received by any household members during this period. If anyone receives unemployment, SSI, SSA, VA benefits, retirement pension, child support, disability payments, or income from any other source, you must provide verification of that income. If you did not have any household income, you’ll be asked to attest to that during the process.
  • Past due utility bills, disconnection notices, rental late notices, or eviction papers. These must be in the name of an adult who resides at that address.
  • Rental lease to verify your residence even if you are not seeking rent assistance.

Be sure you have clear, easy to read photos or scanned copies of these documents saved in a location you can access to upload during the form submission process.


If you are ready, click the “Next Page” button below to begin entering your information.

Use the format of 111-111-1111
Use the format of 111-111-1111
Use the format of 111-111-1111
Residence Address
Crisis Assistance Ministry provides support for basic needs support through an agreement with your employer, Atrium Health. Crisis Assistance Ministry may share your employee identification number (Teammate ID) with Atrium Health in order to better understand employee needs. Details on the services you received will not be shared.
Format date as 'mm/dd/yyyy' using '/' as dividers
Select all that apply.
Please note that mortgage assistance is not available using this online application, but you are encouraged to apply for utility assistance here.  For mortgage assistance, please contact the State Home Foreclosure Prevention Project at 1-888-442-8188, or dial 2-1-1 to locate resources in your area.
Assistance Needs
Household Members

Tell us about the people who live in your household, not including yourself.
Members of Your Household
Please do not enter your own information again. 
Only enter additional members of your household on this page.
Format date as 'mm/dd/yyyy' using '/' as dividers
To add more household members, click the link below. 



To upload each document, you will need to use “Choose File” to select the photo/scanned copy for each item listed. All uploaded documents should be clear and legible; no video files can be accepted. 


Social Security
documentation 
for all household members: Social Security (SS) card, documentation
from the SS Administration, W2 form from an employer, paystub with a complete SS number, or W7 if applicable. If you are not registered with the SS Administration, you must provide some form of ID.              
Picture ID 
of person applying for
financial assistance.
                                                     
Rental lease to verify
your residence 
(even if you are not seeking        
assistance with rent).
Proof of household income
over the past 30 days
Include all paystubs received
by any household members
during this period.
If anyone receives unemployment,
SSI, SSA, VA benefits,
retirement pension,
child support, disability payments,
or income from any other source,
you must provide verification of
that income.
Rental late notices or
eviction papers
These must be in the name of an
adult who resides at that address.
Heating / Cooling Bill
Please upload your most recent heating or cooling bill.
Water Bill
Please upload your most recent
water bill.
OPTIONAL: Additional Supporting Documents
Upload any documents not already provided that may be relevant to your case.
Finalize your Application


Once you click the "Submit Form" button below, we will verify your information. You will receive a phone call from Crisis Assistance Ministry within a few days to gather additional information. Calls are made during business hours, so please monitor the phone number provided for this call. 

Thank you for your patience as we work to serve many people with urgent needs here in Mecklenburg County.

Save my progress and resume later | Resume a previously saved form

Contact Information