Utility Assistance Application Client Intake Form
Funding is provided by United Way of Gaston County, Community Foundation, Energy United Foundation and various donors. This is only an application and does not guarantee assistance. Please provide as much information as possible. The amount of funding is based on different factors and types of funding available.
Client Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email - (THIS IS HOW WE WILL COMMUNICATE ABOUT THIS APPLICATION)
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
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Household and Financial Information
How many total people live in your home?
Total number of people who reside in home
Please answer for EVERY person living in the home INCLUDING yourself and children. (To add information for another person, click add person)
*
Please answer yes or no for each field
Yes
No
Does anyone in the home receive SSI?
Does anyone in the home receive food stamps?
Does anyone in your home have an active cancer diagnosis?
Is this the first time requesting utility assistance through our agency?
Which best describes your living status?
*
Homeowner
Renter
Roomer/Boarder
Landlord's Name/ Apartment Complex
Phone number
How much is your rent?
*
How long have you been living at this address?
Do you receive assistance with housing through HUD or section 8?
*
Yes
No
Does it state in your lease that you must maintain utility service to avoid eviction?
*
Yes
No
What is the total monthly income for the ENTIRE household?
Please enter total amount
What recent change or emergency led to this request?
Does your household follow a financial budget?
Please Select
Yes, we budget every month
Sometimes, we have a hard time sticking to the budget
Rarely, we do not really discuss finances
No, we do not have a set household budget or discuss finances
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Utility Service Information
Please fill out all fields
Due date of bill
-
Month
-
Day
Year
Date
Cut off date if listed
-
Month
-
Day
Year
Date
Please upload a copy or picture of your FULL utility bill.
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Additional Information
By signing below, you agree that this document was filled out in full and complete with all correct information. You understand that this is an application for assistance and does not guarantee assistance. If your application proceeds to the next stage, you may be required to submit other documents such as copy of current bill or cut off notice, copy of lease, housing voucher, or other documents.
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