Emergency Services Application

Emergency Services Application

(Water, Sewer, Home Heating, etc.)
Date

MonthDayYear
Date
Household Information

Please fill out a section for each member of the household

	Full Name	Relationship to Head of Household	Social Security Number	Date of Birth	Gender	Race	Ethnicity
Head of Household (Self)
Household Member
Household Member
Household Member
Household Member
Household Member

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status

SingleMarriedDivorcedWidowed
Are you a Veteran or currently serving in the Military?

YesNo
Are you employed?

YesNo
What is your primary language?

EnglishSpanishOther
If other, please list here
What type of housing do you live in?

RentalOwnSubsidizedOther
If other, please list here
Has your home been weatherized?

YesNoUnsure
If yes, when?
Does the household receive income?

YesNo
If yes, please list the source(s), amount(s), and who they are received by:
Are you behind with your water or sewer bill?

YesNo
Do you have a shutoff notice?

YesNo
How much do you owe?

Please fill out information for water & sewer provider

	Name of Provider	Account Number
Water & Sewer Provider

Date

MonthDayYear
Date
Signature

Clear
Documents Needed for application

30 days of income for household members over 18

Copy of ID front and back for household members over 18

Social Security Card (if available)

Current Water Bill

All these Items can be emailed to calligood@clmcaa.com
File Upload

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