Assistance Application Form

Financial Assistance Application

This is an application for assistance with utilities (water, gas, electricity and/or internet). If you have any questions about this application, please send an email to assistance@globalimpactatl.org.
Contact Information
Title: *
Name *

First Name Last Name
Birth Date *

Month Day Year
Marital Status: *

Single Married
E-mail *
example@example.com
Phone (Please ensure you can be reached at this number in case of questions.) *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence *
Please upload a copy of your driver's license. *

Cancel of
Requested Assistance *

Electricity Gas (Home Heating) Water
Please itemize the assistance that you are requesting. Include bills amounts and vendor for each item. *
Please upload documentation that supports your financial need based on a COVID-19 related event (i.e. job loss, income reduction, disconnection notice, eviction notice, late rent/mortgage notice, utility bill(s)) *

Cancel of
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. * *

YES
Signature *

Clear
Should be Empty:

Financial Assistance Application