Emergency Assistance Application

Please be aware that not everyone who completes this form will receive assistance. The information you provide will help us determine your eligibility.

When you come to Fayette Cares to apply for help, please bring the following:

  • Picture ID for all adults, including children age 18 and over
  • Social Security cards for everyone in the household
  • Proof of your address
  • Proof of your crisis situation (employment separation notice, doctor/repair bills, fire or crime report)
  • Proof of all household income (pay stubs, child support letter, unemployment documentation, social security letter, food stamp letter)
  • Proof of food stamp amount, or application appointment/denial letter
  • Your utility cutoff notice, notice of late rent or mortgage payment

Privacy

Fayette Cares participates in the West TN Homeless Management Information System (HMIS) by collecting information, over time, about the characteristics and service needs of men, women, and children experiencing homelessness or at-risk of homelessness and other forms of crisis. To provide the most effective services we need to collect some identifying personal information including but not limited to: name, birth date, social security, race, gender and current housing situation.

We will guard this information with strict security policies to protect your privacy. If you ever suspect your data in HMIS has been misused, immediately contact the West TN HMIS Administrator at (731) 651-1020.

Federal and/or State law specifically require that any disclosure of substance use, alcohol or drug, mental health, or AIDS related information must be accompanied by the following statement:

This information has been disclosed to you from records protected by the federal confidentiality rules (42 CFR Part 2):  The Federal rules prohibit you from making any further disclosure of information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part2.  A general authorization for the release of medical or other information is not sufficient for this purpose.  The Federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug use patient.

West TN HMIS Participating Agencies:  Aspell Recovery Services, Area Relief Ministries, Benton County Ministerial Alliance, Community Action Network, Carey Counseling Center,  Damascus, Dream Center, Fayette Cares, Hope Ministries, Jackson Housing Authority, JACOA, Jesus Cares, Pathways Behavioral Health Services, Professional Care Services, Matthew 25:40, Inc.,  Quinco Mental Health Centers, SW Human Resource Agency, Tennessee Homeless Solutions and WRAP.

This Authorization will remain in effect unless revoked in writing to this agency. Revocation of this authorization may take up to three (3) business days to process.