Luzerne County ARPA (American Rescue Plan Act) Heating & Utility Assistance Program

Check off all of the statements that are true for you.

I live in Luzerne County.I need assistance with a heat related utility bill - water, electric, gas or deliverable fuel.My name is on the utility bill that I am applying for assistance with.I live at the service address on the utilty bill.I have NOT yet received assistance through this program (ARPA Heating and Utility Assistance Program).

Please note the following income guidelines. Your income must be less than the amounts noted below.
If you believe your income falls within in these limits, please click next.

Household Information
How many people are in your household?

List the following information for ALL occupants of the household. Household means all related or unrelated persons who share living arrangements and benefit from the utility for which you are applying. Start with yourself. Failure to list all household occupants will result in disqualification from the program.*

	Full name & relationship to applicant	Date of Birth (use 4 digit year, for example 01/01/1978)	Social Security Number
Household members, starting with yourself
Spouse or significant other
Other household member
Other household member
Other household member
Other household member
Other household member
Other household member

List ALL gross income received by ALL household occupants, from ALL sources. Failure to disclose all income will result in your disqualification from the program.*

	Name of person with income	Source of income	How much pay?	How often paid?	Date of most recent payment
1
2
3
4
5

Upload proof of gross income before any deductions *

Proof of ALL gross income from the past 30 days prior to application date. Income includes earned (i.e income statements, letter from employer, paystubs) and unearned (i.e child support, private pensions, social security retirement, social security disability (SSD), supplemental social security income (SSI), TANF, Unemployment Compensation, utility reimbursements, Veteran’s Disability, Veterans Pension, Workman’s Comp).
Cancelof

Attestations & Certifications
By initialing below, I attest that my household has experienced financial hardship which may include, but is not limited to, a period of unemployment, a decrease in household income or had increased household costs during the COVID-19 Pandemic.
Initials*
I have uploaded the following items to my application and acknowledge that my application will not be reviewed with out these required items:*

Proof of income for the last 30 days (not just one paystub)Utility bill or receipt with account number for my deliverable fuelPhoto ID - front and back
You must attach the items noted above for your application to be reviewed.

Please review the list again. To upload additional items, click the back button below and add attachments.
By signing below, you are agreeing to the following statement: "I acknowledge that all information and documentation provided are correct and complete and I understand that providing a written false statement which I do not believe to be true is a misdemeanor of the third degree and is punishable as perjury under Pennsylvania Title 18, Section 4904, related to unsworn falsification to authorities, and that in addition to any other penalty that may be imposed, a person convicted under this section shall be sentenced to pay a fine of at least $1,000."
Signature*

Clear
Name*
Date*

MonthDayYear
Date

Thank you for completing the application for Luzerne County Utility Assistance. Please click the dark green submit button.

You will receive an email copy of your responses.

You are not eligible for this program.

You may be eligible for another program: LIHEAP through the Department of Human Services (apply online at https://www.compass.state.pa.us) LIHEAP Crisis if you have a shut-off notice, are out or nearly out of deliverable fuel or if your heating system is inoperable. Please visit www.ceopeoplehelpingpeople.org/crisis to find out how to apply or contact CEO's Utility Department at 570-826-0510 or 570-455-4994 in Hazleton. Customer Assistance Programs are also available to help manage your utility bills. Visit https://www.ceopeoplehelpingpeople.org/utility_and_heating_assistance or contact your utility company for how to apply for help.
Should be Empty:

Please note the following income guidelines. Your income must be less than the amounts noted below.

If you believe your income falls within in these limits, please click next.

Luzerne County ARPA (American Rescue Plan Act) Heating & Utility Assistance Program

Applicant Information

Household Information

Utility Information

IMPORTANT: Please notify your utility company that you are applying for assistance and update your household size and income information.

Attestations & Certifications

By initialing below, I attest that my household has experienced financial hardship which may include, but is not limited to, a period of unemployment, a decrease in household income or had increased household costs during the COVID-19 Pandemic.

You must attach the items noted above for your application to be reviewed.

Thank you for completing the application for Luzerne County Utility Assistance. Please click the dark green submit button.

You are not eligible for this program.