Application for Utility Assistance Program

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.
Do you live in Gaston County, North Carolina*
Unfortunately, you are not in our service area. The Dallas High Shoals Christian Ministry is a crisis agency that serves the residents of Gaston County with a financial focus on Dallas, High Shoals, Stanley, and Alexis.

If you feel you have reached this page in error, please try again or contact us at dallasministry@gmail.com
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email - (THIS IS HOW WE WILL COMMUNICATE ABOUT THIS APPLICATION)*

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.

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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Should be Empty:

	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?

Utility Assistance Application Client Intake Form