New Life Congregational Care Ministry- Utility Assistance Intake Form

New Life Congregational Care Ministry — Utility Assistance Application

Thank you for reaching out to the New Life Congregational Care Ministry. This form is for those requesting help with their electric, gas, or water bill due to the current government shutdown or economic hardship. Please complete all sections and upload required documents. (PLEASE NOTE, THIS PROGRAMS IS EXCLUSIVE TO ACTIVE MEMBERS OF NEW LIFE CHRISTIAN CHURCH) If you are not a member and are in need of assistance, please contact United Way's 2-1-1 for services near your area.
SECTION 1 – Personal Information

Please complete the information requested below
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth
TOTAL Number of Household Members
Number of ADULTS
Number of CHILDREN
Are you a member of New Life Christian Church? (PLEASE NOTE, THIS PROGRAMS IS EXCLUSIVE TO ACTIVE MEMBERS OF NEW LIFE CHRISTIAN CHURCH) If you are not a member and are in need of assistance, please contact United Way's 2-1-1 for services near your area.
Employment Status:
SECTION 2 – Assistance Details
Type of Utility Assistance Needed
Utility Company Name:
Account Number:
Total Amount Due:
Due Date (mm/dd/yyyy):
Is your bill in shut-off or past due status?
Briefly describe your current hardship or situation (2–3 sentences):(Example: “I am a furloughed federal employee waiting for back pay. My bill is due this week.”)
SECTION 3 – Document Uploads

Please use this section to upload the necessary documentation to assist you with your request.
Upload a Valid Photo ID (Driver’s License, State ID, Passport)

Cancelof
Upload a Copy of Your Utility Bill (must show name, address, due date, and account number)

Cancelof
SECTION 4 – Certification

Please use this section to electronically certify your information.
Please Certify to each statement by checking the boxes.
SECTION 5 –Connection

From The New Life Christian Church STORM Ministry
Would you like prayer or pastoral follow-up from the New Life Care Team?
Signature
Should be Empty:

New Life Congregational Care Ministry — Utility Assistance Application

SECTION 1 – Personal Information

SECTION 2 – Assistance Details

SECTION 3 – Document Uploads

SECTION 4 – Certification

SECTION 5 –Connection