Emergency Services Application
(Water, Sewer, Home Heating, etc.)
Date
-
Month
-
Day
Year
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)
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Household Member
Male
Female
Prefer not to disclose
American Indian/Alaskan Native
Asian American
White/Caucasian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic
Non-Hispanic
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marital Status
Single
Married
Divorced
Widowed
Are you a Veteran or currently serving in the Military?
Yes
No
Are you employed?
Yes
No
What is your primary language?
English
Spanish
Other
If other, please list here
What type of housing do you live in?
Rental
Own
Subsidized
Other
If other, please list here
Has your home been weatherized?
Yes
No
Unsure
If yes, when?
Does the household receive income?
Yes
No
If yes, please list the source(s), amount(s), and who they are received by:
Are you behind with your water or sewer bill?
Yes
No
Do you have a shutoff notice?
Yes
No
How much do you owe?
Please fill out information for water & sewer provider
Name of Provider
Account Number
Water & Sewer Provider
Date
-
Month
-
Day
Year
Date
Signature
Please verify that you are human
*
Submit
Should be Empty: