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
U.S. Veteran?/¿Eres un veterano de los Estados Unidos?
*
Yes
No
Monthly household income/ingreso total por casa
*
If none, enter 0
Snap $
*
If none, enter 0
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
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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 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?
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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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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
Below is a list of providers we are CURRENTLY have funds to assist with./Seleccione los proveedores para los que necesita asistencia:
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4Change Energy (Once per calendar year)
Express Energy (Once per calendar year)
Veteran Energy (Once per calendar year)
Please select the providers you are in need of assistance for/Seleccione los proveedores para los que necesita asistencia:
*
City of Mesquite Water (Once per 12-month period)
Ambit Energy (Once per calendar year)
Tri-Eagle (Once per calendar year)
4Change Energy (Once per calendar year)
Express Energy (Once per calendar year)
Veteran Energy (Once per calendar year)
Atmos Energy (3 times per year, not consecutively)
TXU (Once per calendar year)
Please upload a copy of your current bill(s)./Cargue una copia de su(s) factura(s) actual(es).
*
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of
I understand that the provider I selected above must be the same provider as the bill uploaded above/Entiendo que el proveedor que seleccioné anteriormente debe ser el mismo que la factura cargada anteriormente
*
Yes, bill matches the provider selected/Sí, la factura coincide con el proveedor seleccionado
I hereby authorize the selected provider 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.
*
Submit/Enviar
Should be Empty: