Sharing Life Financial Assistance Form
Please note that filling out this form does not guarantee assistance. Once you fill out this form a staff member will review your application and will be in touch as quickly as possible.
Name/Nombre
*
First Name/Primer nombre
Last Name/Apellido
Date of Birth (Month/Day/Year)/ Fecha de nacimiento
*
M/DD/YYYY
Gender/ Género
Female/ Femenino
Male
Other
Name as it appears on bill/El nombre aparece en la factura.
*
Account#/# de Cuenta
*
Email/dirección de correo electrónico
*
example@example.com
Phone Number/número de teléfono
*
Please enter a valid phone number.
Address/dirección
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race
*
American Indian or Alaska Native
Asian
Black of African American
Native Hawaiian or Other Pacific Islander
White
Other
Ethnicity
*
Hispanic/Latino
Not Hispanic/Latino
Monthly household income/ingreso total por casa
*
If none, enter 0
Snap $
*
If none, enter 0
U.S. Veteran?/¿Eres un veterano de los Estados Unidos?
*
Yes
No
Is anybody in your household disabled?
*
Yes
No
Has anybody in your household been affected by Covid-19?
Yes
No
Please list individuals in household/Indique las personas en su casa
*
Name (nombre)
Date of Birth (fecha de nacimiento)
Relationship to head of household(Relación con el jefe de hogar)
Gender (género)
1
2
3
4
5
6
7
8
Please select the providers you are in need of assistance for/Seleccione los proveedores para los que necesita asistencia:
*
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-City of Mesquite Water (Once per 12-month period)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-Ambit Energy (Once per calendar year)
Tri-Eagle (Once per calendar year)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-4Change Energy (Once per calendar year)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-Express Energy (Once per calendar year)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-Veteran Energy (Once per calendar year)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS- Atmos Energy (3 times per year, not consecutively)
-DO NOT APPLY. CURRENTLY OUT OF FUNDS-TXU (Once per calendar year)
I hereby authorize the selected provider(s) I've checked above to disclose information regarding my account to Sharing Life Community Outreach. I also authorize Sharing Life to act on my behalf in pledging payment on the account within the boundaries of these providers/Por la presente, autorizo al(los) proveedor(es) seleccionado(s) que he marcado arriba a divulgar información sobre mi cuenta a Sharing Life Community Outreach. También autorizo a Sharing Life a actuar en mi nombre para comprometer el pago de la cuenta dentro de los límites de estos proveedores.
*
Please explain below what caused you to be behind in payments./Explique a continuación por qué se atrasó en los pagos.
*
Have you received assistance in the past 12 months from any other agency, organizations, churches, or welfare?/¿Ha recibido asistencia en los últimos 12 meses de alguna otra agencia, organización, iglesia o asistencia social?
*
Yes
No
If you answered "yes" to question above, please list the organization/church./Si respondió "sí" a la pregunta anterior, indique la organización/iglesia.
*
Have you had a pledge from Sharing Life in the last 12 months?/¿Ha tenido un compromiso de Sharing Life en los últimos 12 meses?
*
Yes
No
Date:/Fecha
*
-
Month
-
Day
Year
Date
Please upload proof of income for EACH MEMBER of the household, /Cargue un comprobante de ingresos de cada miembro del hogar.
*
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of
Please upload an ID card for EACH MEMBER of the household/Cargue una tarjeta de identificación para cada miembro del hogar
*
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of
Please upload a copy of your current bill(s)./Cargue una copia de su(s) factura(s) actual(es).
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit/Enviar
Should be Empty: