Utility Assistance Form

Utility Assistance Form

SECTION 8 DOES NOT QUALIFY FOR UTILITY ASSISTANCE. SECCIÓN 8 NO CALIFICA PARA ASISTENCIA DE LUZ O GAS. Please submit electric bill (disconnection notice or past due). Por favor presentar factura eléctrica (aviso de desconexión o vencida).
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County/Condado*
How many adults are in the home?*
Are you an existing client?*

YesNo
How many children are in the home?*
Utility Company*
Are you the customer or authorized user on the account?*

YesNo
Do you Have a Disconnection Notice or a Past Due?*

YesNo
Have you received assistance from another organization within the last 90 days?*

YesNo
If you answered YES to the question above, we are sorry but we can't provide assistance at this moment.
***Failure to submit all of the documents on here will result in automatic disqualification.***

***No subir todos los documentos aquí resultará en descalificación automática.***

Please upload the following:
- ID's for all adults in the home
- proof of income for all the adults for the last 30 days
- birth certificates for all children under the age of 17
- Upload lease.
Please include bill (Atmos, NRG & TXU ONLY)

Por favor suba los siguientes documentos:
- ID's para todos los adultos
- ingresos de los últimos 30 días para todos los adultos
- actas de nacimiento para menores de 17
- subier contrato de alquiler.
Por favor incluya factura (Atmos, NRG & TXU SOLAMENTE)
File Upload*

Cancelof
Should be Empty: