The Utility Assistance Grant

To Qualify You Must:

• Be responsible for paying residential utility expenses
• Provide a fax, attachment, or email of your most recent utility bill
• Attest that you are struggling to meet your monthly bills 

As a Utility Assistance Grant applicant, I do hereby give permission to obtain and release personal information regarding my case to utility companies as deemed necessary to further assist my household in accessing funding sources. Information requested / released may include, but is not limited to, the following: 1) Services provided to or requested from the household by The Source Ministries, Inc. ; 2) Status of utility accounts, payment and consumption histories; 3) Residency and household members.

• The information provided is true and correct to the best of my knowledge and belief.
• I hereby authorize The Source Ministries, Inc. to obtain information from my utility account  for the purpose of obtaining my billing history, and account balance to be used for the sole purpose of determining my eligibility for benefits of the Utility Assistance Grant . I understand that the account information obtained by my utility companies may contain personal and/or personally-identifying information.
• I understand that The Source Ministries, Inc. will not use my information provided except as needed to review this application to determine eligibility.
• I am aware that I am subject to federal prosecution for providing false or fraudulent information.

My signature indicates I have read the Release of Customer Information, Application Required Document List, and agree to abide by the terms stated.

Please upload the two most recent utility statements.

(These statements can be obtained from your online utility account, or from the utility company if you no longer have your statements)

*You may also fax these statements to 417.281.3366 ATTN: The Source/Utility Assistance Grant. Please note that your application cannot be processed until these statements are received.