Community Lifeline Financial Intake Application

Utility Assistance
Including yourself, how many individuals are in the household?*
How many are between ages 0-17 in the household?*
Please describe the temporary/unforeseeable crisis that caused you to be unable to cover rent/utilities in detail. *
Please upload proof of your unforeseen crisis:*

For example: Emergency surgery that took funds from your bill, upload paid medical bill.
Cancelof
Select your utility provider.*

CoServCirro EnergyAtmosMcKinney WaterTXU EnergyReliant
Most Recent Bill (with account number and name on account visible)*

Must show current balance and account number. Account must show applicant's name.
Cancelof
Please upload proof of income for each individual in the household over 18:*

Must show current balance and account number. Account must show applicant's name.
Cancelof
If CLC can help you with utilities for one month, will you be able to make your utility payments independently in the upcoming months?*

YesNo
Please explain in detail your Plan of Action for paying your upcoming bills in the months to come.*

Community Lifeline Agreements
All information submitted is true and accurate at the time of the application.*

I agree
I authorize Community Lifeline Center to access my utility account and authorize my utility provider to release information to Community Lifeline Center Staff.*

I agree
I understand submission of this application does not guarantee assistance/approval through Community Lifeline Center.*

I agree
Signature*

Clear

Thank you for completing the application. Unfortunately, you do not qualify for our Financial Assistance Program. Please submit the application on the next page so a Case Manager may reach out to you via email to provide more information and additional resources.
Name*

First NameLast Name
Please enter your email to receive additional information about your application.*
example@example.com

Submit Application

You have completed the application. Please hit the submit button below.
Should be Empty:

CLC Financial Intake Form - Utilities