Language
English (US)
Español
Daystar Utility Assistance Information Form
Must Be Completely Filled Out
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What is the best time to contact you?
*
Hour Minutes
AM
PM
AM/PM Option
Gender
*
Male
Female
Non-binary
Race
*
Please Select
African American
Asian
Caucasian
Hispanic
Middle Eastern
Native American
Other
Pacific Islander
Education
*
College
High School Incomplete
High School/Ged
N/A
Employment
*
Full Time
Part Time
Unemployed
2 Jobs
3 Jobs
Martial Status
*
Divorced
Married
Single
Veteran
*
Yes
No
Government benefits
*
Receives Food Stamps
Receives Medicaid
Receives Social Security
Receives Veteran Benefits
Receives WIC
Receives Government Housing Subsidy
Disability Status
*
Disabled
Not disabled
Prefer not to answer
Other
*
At Risk of Being Homeless
Homeless
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Number of Children in the Household
Number of Adults in the Household
*
Back
Next
Daystar Utility Assistance Information Form
Page 2
Household Members (please put name, date of birth, SSN for each)
HOUSEHOLD INCOME (please include total for everyone - Please fill out all lines)
*
Back
Next
EXPENSES (Please fill out all lines - If none use 0)
*
Daystar Utility Assistance Information Form
Page 3
Proof of Income (pay stub, SSI, etc.) If you are not currently employed, please upload a letter stating the start date of your unemployment.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Copy of Utility Bill (Please only upload the first page of the bill)
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Why are you in need of assistance?
*
Privacy Policy Agreement
By checking this box you acknowledge you have read and agree to Daystar Life Center's Privacy Policy linked below.
Daystar Life Center's Privacy Policy
Should be Empty: