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Application for Utility Assistance.
*
Indicates required field
Name
*
First
Last
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Employed?
*
Yes
No
Employer Name:
*
Receiving Unemployment?:
*
Yes
No
Monthly Salary/Unemployment:
*
Spouse Employed:
*
Yes
No
Spouse Employer Name
*
Spouse receiving unemployment?
*
Yes
No
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:
*
Yes
No
Option 3
Roommate Name:
*
Spouse Name:
*
First
Last
Email
*
Phone Number
*
Submit
Welcome
About
Board of Directors
Get Help
Ways to Help
Community Supporters
Volunteers
Wish List
Donate
News and Events
SouthBay Magazine
Blog - I CARE
Contact Us
Support Us