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.
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.
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?*

YESNONOT YET
Employment Status:*

Full-timePart-timeUnemployedFederal Employee (furloughed/unpaid)Retired
SECTION 2 – Assistance Details
Type of Utility Assistance Needed*

ElectricityWaterGas
Utility Company Name:*
Account Number:*
Total Amount Due:*
Due Date (mm/dd/yyyy):*
Is your bill in shut-off or past due status?*

YesNo
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.*

I certify that the information provided is true and accurate.I understand that funds are limited and submitting this form does not guarantee assistance.I give New Life Christian Church permission to verify my documentation and contact me regarding this request.
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?

Yes, please have someone contact me.No, not at this time.
Signature*

Powered by Jotform SignClear
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