H2O Community Customer Survey

Thank you for trusting H2O Community. We would love to hear about your experience with our water bill assistance program.

Date:

Month Day Year

Your Name: *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

E-mail

example@example.com

Reason for Assistance (check all that apply) *

Loss of Income Change in Household: separated, divorced, death in the family Medical Expenses Natural Disaster: causing substantial home repairs Other

Any important notes about your circumstance?

Please rate the following:

The assistance I received helped stabilize my household. *

Definitely Somewhat Not at all Not Applicable

I ultimately received the services and/or information I needed. *

Definitely Somewhat Not at all Not Applicable

If needed, would you apply for H2O Community funds again? *

Yes No

Would you recommend H2O Community if you knew someone that could use our help? *

Yes No

Can we use your story as a testimonial for H2O Community? *

Yes No

If yes, can we use your name? If no, we will keep your identity anonymous. *

Yes No

How can H2O Community better serve you?

Additional Comments: