Utility Assistance Program Application

Young College Mothers

Tallahassee, Fl

contact@youngcollegemothers.com

www.youngcollegemothers.com

(850)320-1441
Utility Assistance Program Application

Fill the form below and we will get back soon to you for more updates.
Head of Household Information*

First NameLast Name
Date of Birth

DayMonthYear
Work Phone Number*
Home/Cell Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever applied for utility assistance from Young College Mothers, Corp.?*

YesNo
Housing Type*

Sing-family homeApartment/CondoTownhouseMulti-family HomeMobile HomeModular HomeOther
Do you or anyone in the Household receive any items from the list below?:

SNAPWICLIHEAPHousing VoucehrPublic HousingChild Care SubsidyHUD VASHOtherOther
Monthly Gross Income:*
Monthly Rent/Mortgage:*
Upload All Documents Here:*

Cancelof
Provide copies of the following:

(Application is considered incomplete if all documents are not received)
- Most recent home energy bill;
- Proof of Income (paycheck stubs or other proof that shows your current gross income);
- Photo identification of the applicant and other household members or any document that establishes parent or child identity will be accepted;
- Proof of U.S. citizenship or permanent residence;
- Proof of enrollment in an undergraduate program pursuing an Associate’s, a Bachelor's or Vocational degree.
Applying does not guarantee that you will automatically receive assistance. Depending on the funds available, you may be able to apply for assistance up to two times a year.
Should be Empty: