Utility Assistance Self-Service Packet

Funding for the Rental and Mortgage assistance due to COVID has been expended for 2020. Funding and applications will be available in early January 2021.

Visit https://www.mesaaz.gov/government/mesa-cares for more information.
- Utility Assistance Self-Service Packet
- Required Documentation
  
  Please provide one from each category for EVERYONE in the household, if you have any questions please contact our office. You will not be able to proceed to the application without this documentation.
- Proof of Income
  
  EARNED and/or UNEARNED income will be considered in determining eligibility for services. The gross amount of income prior to deductions will be counted unless otherwise specified. Income will be counted as received at the time it is made available to the household.
  
  Proof of income for the past 30 days for everyone in the household-this includes paycheck stubs, current benefit award letters, unemployment paperwork, child support information, school financial aid information.
  - Wages- Paycheck stubs
  - Self-Employment Income- Business Ledger
  - Babysitting/Child Care Income- Signed and dated statement by the person paying for the care
  - Housekeeper/Home health aides- Signed and dated statement by the employer
  - Social Security- Current benefit award letter
  - Unemployment Insurance- Award letter, printout of payments received
  - Retirement/Pension Income- Provide written verification from source
  - Alimony- Provide court paperwork
  - Child support- Provide written verification from the court or Signed and dated statement from the absent parent
  - Cash Assistance- Provide written statement by DES
  - Gambling Industry- Provide per capital disbursement verification
  - Contribution and Complimentary Assistance (cash) - Provide signed and dated statement
  Anyone 18 or older with no income will need to provide written documentation from the income source of the last date employed and last date paid, they will need to write a “0 income statement” which is a letter stating they have had no income and they must provide proof of how they have been surviving without any income.
- Proof of Income
  
  Click to upload or take picture
  Cancelof
- Proof of Citizenship
  
  BIRTH CERTIFICATES FOR EVERYONE IN THE HOUSEHOLD
  
  If you were not born in the US, you must give proof of citizenship or legal permanent resident status.
  
  Proof of citizenship - any of the following forms are acceptable, Birth certificate, Passport, passport card, C.I.B., military discharge paperwork or DD-2form, certificate of live birth, recent Social Security income award letter, recent DES nutrition or cash assistance award letter with the name and date of birth.
  
  If born outside of the U.S., please provide proof of or legal permanent resident status or U.S. citizenship. If you have had a name change please include documentation verifying the name change i.e. Court Order, Marriage Certificate.
  - Picture I.D. from everyone 18 and older
  - Social Security Cards or any legal document with the name and social security number for everyone in the household
- Proof of Citizenship
  
  Click to upload or take picture
  Cancelof
- Utility
  
  Please upload a current copy (with first and last name) of one of the following documents for proof of utility information:
  - Utility bill, MPower receipt, or Utility Deposit Letter
- Proof of Utility
  
  Click to upload or take picture
  Cancelof
- Residency/Landlord Verification, W9, TIN
  
  Please upload a current copy (with first and last name) of one of the following documents for proof of residency information:
  - Current Lease Agreement, Mortgage Statement or Property tax information
- Residency/Landlord Verification, W9, TIN
  
  Click to upload or take picture
  Cancelof
- Self Service Intake
  
  Applicant Information
- Applicant's Name
  
  First NameMiddle InitialLast Name
- Social Security Number
- Phone Number
  Format: (000) 000-0000.
- Message Number
  Format: (000) 000-0000.
- Email
  example@example.com
- Are either you or a member of your family an A New Leaf employee?
- If Yes, name of employee:
- What is the primary language in the household?
- If Other, what language?
- Gender
- Race
- Ethnicity
- Tribe
- Residential Address
  
  Street Address (Street Number, Street Name, Apt. Number)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Is your Residential Address different than your Mailing Address?
- Mailing Address
  
  Street Address (Street Number, Street Name, Apt. Number)
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- How many people live in your household (including applicant)?
  ex: Just the applicant = 1, Applicant & Spouse or partner = 2
- Is there a Veteran in your household?
- If Yes, how many?
- Is there anyone disabled in your household?
- Homeless?
- Household Health Insurance
  
  AHCCCSKidsCareMedicareVAThrough EmploymentPrivate / Direct PurchaseTribalNone
- What is your Health Plan?
- What is your Health Plan ID or Number?
- What is your housing type?
- What is your family type?
- If Other, please explain:
- Monthly Utility Cost
- Do You live in Subsidized Housing?
- What type of home do you live in?
- If Other, please explain:
- Has the household received rental assistance in the past 12 months?
- Date of arrival to the state
  
  MonthDayYear
- Date of arrival to the county
  
  MonthDayYear
- Is there a Domestic Violence situation in the home?
  CONFIDENTIAL: This question will be concealed upon answering YES
- Court ordered child support?
- Is your household receiving SNAP benefits (food stamps)?
- Is your household receiving Unemployment benefits?
- Is your household receiving other benefits or income?
- If your household is receiving other benefits or income, please explain:
- Income Information Notes
- What is your marital status?
- Crisis Reason
- Please document crisis here
- Do you make utility payments?
- Is your utility payment Past Due, have your received a disconnect notice, or are you low on fuel (very little on M-Power, Propane, etc.)?
- HOUSEHOLD MEMBER 1 - Applicant
- Applicant Name
  
  First NameMiddle NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 2
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 3
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 4
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 5
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 6
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 7
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 8
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 9
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- HOUSEHOLD MEMBER 10
- Name
  
  First NameLast Name
- Social Security Number
- Date of Birth
  
  MonthDayYear
- Place of Birth
- Last Grade Completed
- Health Insurance?
- Race
- Relationship to Applicant
- How many Income Sources does this household member have?
- 1. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 2. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 3. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- 4. Income Source
  Name & Number
- Frequency
- Date Received
  
  MonthDayYear
- Gross Amount Received
- Total Gross Income Amount
- Release of Information
- AUTHORITY FOR RELEASE OF INFORMATION:
  
  By signing below, I agree to participate in the Emergency Services Network and utilize MesaCAN as my primary service agency, I authorize MesaCAN and/or delegate agency to contact any source necessary to establish the accuracy of the information given by me and to release or receive information contained on this form and/or in my case file.
  
  APPLICANT’S STATEMENT OF TRUTH:
  
  Under Penalty of perjury and acknowledged by my signature below, I SWEAR or affirm that the statement made regarding the persons in my home, and the income, resources, property and all other items that pertain to my possible eligibility for benefits are TRUE and CORRECT to the best of my knowledge.
  
  Bajo penalidad de perjurio y reconocido por mi firma abajo, yo juro o afirmo que las declaraciones hechas en cuanto a las personas en mi hogar, y los ingresos, los recursos, propiedad y todas cosas demás que pertenecen a mi elegibilidad posible por beneficios son verdaderos y ciertas según mi leal entender y saber.
- Applicant Name
  
  First NameLast Name
- Signature Date
  
  MonthDayYear
- Applicant Signature
- STAFF USE ONLY
  
  ANY CHANGES MAY PREVENT YOUR APPLICATION FROM BEING PROCESSED
- ツ
- CM REVIEW
  
  Application Voucher
- Application Status
- Review Date
  
  MonthDayYear
- Case Manager: Enter your username
- Case Manager First Name
- Case Manager Last Name
- Case Manager Email
- Additional Documents
  
  Cancelof
- Application Notes
- Requirements Checklist
- Utilities Requirements Checklist
- Rent Requirements Checklist
- What type of assistance has been requested?
  
  City of MesaSRPSouthwest GasPrimary RentalSecondary Rental
- com_manual_voucher_nbr
  Use this voucher number, if available. Otherwise, use the voucher number in the next field.
- Account Number
- Is this account under a different name than the applicant?
  
  YesNo
- Alternate Billing Name
  Make sure they complete the ROI
- Amount Approved
- Status
- Status Date
  
  MonthDayYear
- Denial Reason
- Voucher Comments
- Case Manager Signature
- Case Manager Signature Date
  
  MonthDayYear
- Finance Review
- Finance Determination
- Finance Reviewer: Enter your username
- Finance First Name
- Finance Last Name
- Finance Signature
- Finance Signature Date
  
  MonthDayYear
- Payment Status
- Payment Amount
- Date Paid
  
  MonthDayYear
- srp_manual_voucher_nbr
  Use this voucher number, if available. Otherwise, use the voucher number in the next field.
- Account Number
- Is this account under a different name than the applicant?
  
  YesNo
- Alternate Billing Name
  Make sure they complete the ROI
- Amount Approved
- Status
- Status Date
  
  MonthDayYear
- Denial Reason
- Voucher Comments
- Case Manager Signature
- Case Manager Signature Date
  
  MonthDayYear
- Finance Review
- Finance Determination
- Finance Reviewer: Enter your username
- Finance First Name
- Finance Last Name
- Finance Signature
- Finance Signature Date
  
  MonthDayYear
- Payment Status
- Payment Amount
- Date Paid
  
  MonthDayYear
- swg_manual_voucher_nbr
  Use this voucher number, if available. Otherwise, use the voucher number in the next field.
- Account Number
- Is this account under a different name than the applicant?
  
  YesNo
- Alternate Billing Name
  Make sure they complete the ROI
- Amount Approved
- Status
- Status Date
  
  MonthDayYear
- Denial Reason
- Voucher Comments
- Case Manager Signature
- Case Manager Signature Date
  
  MonthDayYear
- Finance Review
- Finance Determination
- Finance Reviewer: Enter your username
- Finance First Name
- Finance Last Name
- Finance Signature
- Finance Signature Date
  
  MonthDayYear
- Payment Status
- Payment Amount
- Date Paid
  
  MonthDayYear
- prent_manual_voucher_nbr
  Use this voucher number, if available. Otherwise, use the voucher number in the next field.
- Account Number
- Is this account under a different name than the applicant?
  
  YesNo
- Alternate Billing Name
  Make sure they complete the ROI
- Amount Approved
- Status
- Status Date
  
  MonthDayYear
- Denial Reason
- Voucher Comments
- Case Manager Signature
- Case Manager Signature Date
  
  MonthDayYear
- Finance Review
- Finance Determination
- Finance Reviewer: Enter your username
- Finance First Name
- Finance Last Name
- Finance Signature
- Finance Signature Date
  
  MonthDayYear
- Payment Status
- Payment Amount
- Date Paid
  
  MonthDayYear
- srent_manual_voucher_nbr
  Use this voucher number, if available. Otherwise, use the voucher number in the next field.
- Account Number
- Is this account under a different name than the applicant?
  
  YesNo
- Alternate Billing Name
  Make sure they complete the ROI
- Amount Approved
- Status
- Status Date
  
  MonthDayYear
- Denial Reason
- Voucher Comments
- Case Manager Signature
- Case Manager Signature Date
  
  MonthDayYear
- Finance Review
- Finance Determination
- Finance Reviewer: Enter your username
- Finance First Name
- Finance Last Name
- Finance Signature
- Finance Signature Date
  
  MonthDayYear
- Payment Status
- Payment Amount
- Date Paid
  
  MonthDayYear
- Should be Empty:

Utility Assistance Self-Service Packet

Required Documentation

Self Service Intake

HOUSEHOLD MEMBER 1 - Applicant

HOUSEHOLD MEMBER 2

HOUSEHOLD MEMBER 3

HOUSEHOLD MEMBER 4

HOUSEHOLD MEMBER 5

HOUSEHOLD MEMBER 6

HOUSEHOLD MEMBER 7

HOUSEHOLD MEMBER 8

HOUSEHOLD MEMBER 9

HOUSEHOLD MEMBER 10

Release of Information

STAFF USE ONLY

CM REVIEW

Finance Review

Finance Review

Finance Review

Finance Review

Finance Review