Application for Utility Assistance

Application for Utility Assistance.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Employed? *

Employer Name: *

Receiving Unemployment?: *

Monthly Salary/Unemployment: *

Spouse Employed: *

Spouse Employer Name *

Spouse receiving unemployment? *

Spouse Monthly Salary/Unemployment: *

Number of Children under 18: *

Household size: *

Select Utility *

Electric Gas Water/Trash

Customer/Account Number: *

Total Amount Owed: *

Please list government assistance received: (ie, food stamps, WIC, Section 8, etc.): *

Roommate: *

Roommate Name: *

Spouse Name: *

First

Last

Email *

Phone Number *

Submit