New Met Ed Customer Assistance Form

PLEASE READ

Items that are required to complete the referral process: send ALL required documents 1- 4 if necessary to Stacey@familypromisehcr.org

1. Verification of income (30 days)

If you do not have income you will be asked to complete a Zero Income form found at the bottom of page if needed

2. A copy of the most recent utility bill or shut off notice

3. Proof of sincere effort of payment *if the min is not paid, we cannot complete the referral form*

MetEd applicants must have paid at least $150 on their bill in the last three months. PA American Water has waived their minimum payment for the time being.

4. Signed copy of Remote Agreement (since this process is completed online) found at bottom of the page

Balance Requirement:

Appliciants must have a balance on their utility bill of at least $100

Max funding:

The maximum amount funded is $500

Applicants can only recevied one grant per utility, per program year

Eligibility Guidelines:

Account MUST be residential, single home, or apartment. NO "cooking only," commercial, industrial, or apartment with shared utility service.

Name on the account must be that of an adult who is currently living in the home.

Customer Details:

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Format: (000) 000-0000.

E-mail*

example@example.com

Date of Birth *

Date

Monthly Income *

Ethnicity*

Gender*

MaleFemaleChose not to answer

Disabled*

YesNo

Citizen*

YesNo

Veteran*

YesNo

Are you the head of household?*

YesNo

Please provide all of the above information for ALL other household members in the space below. This includes full name and date of birth. *

Housing Status*

Social Security Number

If are not providing your SSN, please let us know why below.

Utility Assistance Form

Utility Information