Application for Utility Assistance
Required documents may be uploaded directly to this application, emailed to info@ccfok.org, faxed to 918-224-6426, or submitted in-person at 12 W. Burnham
Utility Assistance Policy
Must live in CCF Service Area. Assistance amount up to $100 / per household / per 12 months. Bill must be in your name or in the name and current address ( or in the name of a current member of your household). We are unable to assist with deposits or balances from a previous address.
Date
-
Month
-
Day
Year
Date
Where do you live?
*
Sapulpa
Kiefer
Kellyville
Creek Co. Resident with Tulsa Address
Creek Co. Resident with Mounds Address
Creek Co. Resident with Oakhurst Address
Other - Call 211. If you live outside of our service area, you are not eligible for financial assistance from Caring Community Friends. Please go to www.211EOK.org to find help in your local area.
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Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
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Year
What gender do you identify as?
Male
Female
Prefer not to answer
What race of ethnicity do you identify as?
White
Hispanic, Latino, or Spanish
American Indian
Black or African American
Asian
Other
Don't Know / Prefer not to answer
Which Tribe?
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Telephone Number
Household Information
Not including yourself, how many Seniors (55+ yrs) live at your address?
What are their Names (first and last) and Ages?
Not including yourself, how many Adults (18-54 yrs) live at your address?
What are their Names (first and last) and Ages?
Not including yourself, how many Children (0-17 yrs) live at your address?
What are their Names (first and last) and Ages?
Has anyone in your household, including yourself, served on active duty in the U.S. Armed Forces?
No, never served in the U.S. Armed Forces
Yes, on active duty in the past, but not now
Yes, now on active duty
Is anyone in the household currently receiving SNAP/Food Stamps?
Yes
No
Don't know / Prefer not to answer
Total Monthly Household Income
*
Does anyone in your household, including yourself, have a disability?
Yes
No
Don't know / Prefer not to answer
What is your living situation, today?
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live.
Don't know / Prefer not to answer
In the last month, did you or anyone in your household work for pay full-time?
Yes
No
Don't know / Prefer not to answer
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Documentation
Please submit a copy of a Federally Recognized Photo ID, Late Bill or Cut-off Notice (showing usage and total amount due).
Last 4 Social Security Number of the Account Holder
*
Proof of Income (paystub, social security, bank statement, etc.) If zero, please move on to the next question.
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Photo ID Upload
*
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Utility Bill (Showing Usage)
*
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Late Bill or Cut-off Notice
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I understand that I must submit all of the documents, listed above, to complete my application.
*
Yes
No
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Submit
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