ALACHUA COUNTY
DEPARTMENT OF COMMUNITY SUPPORT SERVICES
Division of Social Services
Sarai Cabrera, Director
scabrera@alachuacounty.us
218 SE 24
th
Street Gainesville, Florida 32641
Tel. (352) 264-6750 • Fax (352)264-6756
Rev. 082817
Dear Alachua County Citizen,
Thank you for your interest in the Assessment Hardship Exemption Program. You will need to complete this application,
make your copies, and return the application along with the copies of the documents listed below:
● Photo ID (driver’s license or Florida ID card) for all adult household members
● Social security card for all household members
● Birth certificate for all household members (birth certificate, passport, permanent legal US residency card or other
official documentation of place of birth for US citizenship)
● Proof of all household income for past 60 days - Gross wages (before taxes/other deductions), other countable
income and assets (things you own) for the past 60 days for all household members including: Social Security
retirement, SSI, SSDI, child support payments, alimony, pay check stubs, alimony, income tax return; etc.
● Food stamp benefit letter (issued by DCF or via ACCESS) confirming monthly amount
● Bank Statement(s) for all check, savings, and credit union accounts – most recent statement
NOTE: Additional information may be requested by the Social Service Coordinator after they review your
application packet.
SUBMITTING YOUR APPLICATION AND DOCUMENTS:
Once you have completed, signed the application, and provided copies of the requested documentation (please furnish
your own copies, not the original documents) you may submit it through any of the methods indicated below:
● Drop-off these materials at our office (Mondays – Fridays, 8:30 a.m. to 4:00 p.m.)
● Fax them to our office at (352) 264-6756, ATTN: Social Services
● Mail them to our office (be sure to include enough postage) at:
Alachua County Social Services, c/o Community Support Services Department,
218 SE 24
th
St
Gainesville, FL 32641
● E-mail your completed, signed application and documentation to our office at the following:
NOTE: All submitted copies of documents must be legible (make sure they are readable when copied); we will not
be able to accept or process your application without the requested documents.
NEXT STEPS:
Upon receipt of your application and supporting documentation, you will be contacted by one of our office’s Social Services
Coordinator, who will review your documentation with you and identify any additional information that may be needed to
establish your eligibility for services under our program. If you have any questions, please call our office at (352) 264-6750.
Thank you,
Alachua County – Division of Social Services
Submitting an application is NOT a guarantee that services will be provided.
Alachua County
Department of Community Support Services
Division of Social Services
***THE SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF SERVICES*** Page 1
Application for the Assessment Hardship Exemption Program (AHEP)
INSTRUCTIONS: All sections of the application must be completed; if a section does not apply to your household, enter “N/A”.
Exemption Services Requested: Fire Solid Waste Stormwater
Applicant Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Date Of Birth:
Gender:
Male Female
Marital Status:
Single Married Separated Divorced Widowed
Race: African-American / Black American Indian / Alaskan Native
Asian Native Hawaiian / Pacific Islander White Multi-Racial
Ethnicity:
Hispanic
Non-Hispanic
Veteran:
Yes
No
Status:
US Citizen
Legal Resident
Education: Less than 9
th
grade High School, no diploma HS Diploma/GED Some College AA/AS
BA/BS MA/MS Professional Doctorate
Physical Street Address:
City:
Zip Code:
Home Phone:
Cell Phone:
Alternate Phone:
PO Box/Mailing Address (If Different Than Above):
City:
Zip Code:
Property Parcel #:
Email Address:
Property Details
Have you occupied the property for the past twelve (12) months?
No Yes
Is the property your present primary residence?
No Yes
Do you intend to maintain this property as your primary residence for the remainder of the present tax year?
No Yes
Do you owe property taxes for the year you are requesting assistance?
No Yes
Do you agree to immediately notify the Alachua County Tax Collector’s Office if you vacate or sell the property?
No Yes
Household Income
What is the total monthly gross (before taxes) income for your household?
$
Public Assistance
Does anyone in the household receive TANF Cash Assistance, Food
Stamps, or SSI?
No Yes, Amount:
$
Applicant Employment Information
Employment Status: Full-time Part-time Retired Self-Employed Unemployed Disabled
Other Household Members Information (Include additional household members on blank sheet)
First Name
Last Name
Social Security Number
Date of Birth
Gender
Employed
Relation to
Applicant
Male Female
No Yes
Male Female
No Yes
Male Female
No Yes
***THE SUBMISSION OF AN APPLICATION IS NOT A GUARANTEE OF SERVICES*** Page 2
Assets
Do you have a bank, credit union, and/or prepaid/benefit card account?
No Yes
Do you own a rental property? No Yes
Please list any other asset (car, house, boat, etc.) :
Applicant Certification/Release of Information
I certify that all information I have provided above is true and correct. I understand that my completion of this application is not a guarantee of assistance
from Alachua County Division of Social Services.
I have read the Applicant Certification/Release of Information statement and understand it.
Signature:
Date:
Release of Information and Use of Social Security Number
Release of Information Agreement
I understand that the information provided by me is subject to review and verification by Alachua County through its agents and/or
employees, in order to determine eligibility for the program benefits/services for which I am applying.
Providing inaccurate or incomplete information will result in a denial of services.
I hereby authorize the release of information to Alachua County, from any and every organization or entity, any and all records
concerning employment, income, receipt of benefits, medical records, and financial records, relating to me and any and all members of
my economic unit.
I understand that all information provided to this office is subject to release to other persons and entities pursuant to the Florida Public
Records Law (Section 119.07, Florida Statutes) unless such record is otherwise exempt or confidential by law.
Use of Social Security Number
I, further understand that the Alachua County Department of Community Support Services has requested the disclosure of my social
security number.
I understand that such disclosure is voluntary and that benefits or services provided by Alachua County cannot and will not be denied
based upon a refusal to provide my social security number.
I understand that if I voluntarily release my social security number, it may be used for identification in filing and record taking; for
verification of benefits from other agencies; and other inter-agency communications.
I confirm that the information contained herein is accurate; I also agree to notify Social Services of any changes, included but not
limited to my application, employment, economic unit size, insurance coverage, Alachua County residency, and earned income.
Applicant Signature: ________________________________________________ Date: _________________________
