SI Utility Assistance Application Form

SI Utility Assistance Application

To apply for utility assistance, please complete the following questions.
Are you a Collin County resident?*

YesNo
Who is your utility provider?*

NRG(Cirro, Direct Energy, Discount Power, Green Mountain, Reliant, US Stream, Xoom)AtmosTXUOther

SI Utility Assistance Application
Is the amount you are requesting for one of the following?

FeesPast due amountOther
What is the amount you are requesting?
Do you have a disconnect date? If no, please enter N/A*
MM/DD/YEAR
Have you received financial assistance from The Samaritan Inn in the past 12 months?

YesNo

Applicant Information
Applicant Name*

First NameLast Name
Does your name match the name on the utility account? If not, whose name is on the account? *You will be required to show documentation that you are an authorized user on the customer's account.
Home Address*
This address should be the same as on your utility bill service address.
Apt Number
City*
State*
Zip Code*
Phone*
Email Address*
example@example.com
Email Address (please type again)
example@example.com
DOB*

MonthDayYear
Applicant Sex*
Applicant Race*
Are you Hispanic or Latino?*

YesNo

Required Documents

Please upload clear photos of the following documents.
2. Upload Your Proof of ID*

Driver License or ID, US Passport
Cancelof
3. Upload Your Utility Bill*

Most recent electricity bill. (Account name and account number must be visible.)
Cancelof

The Samaritan Inn Agreements
I understand that submitting this application does not guarantee assistance or approval from The Samaritan Inn, as utility assistance is contingent upon eligibility, availability of funds, and a qualified utility provider.*

I understand
I understand that failure to submit all required documentation or fully answer all application questions will result in an incomplete application.*

I understand
I understand that by submitting this application I am authorizing The Samaritan Inn to access my utility account as well as authorizing my utility provider to release information to The Samaritan Inn.*

I understand
I understand that all information received in this application, as well as any documents received by The Samaritan inn staff throughout this process is subject to the organization’s Privacy Policy.*

I understand
By signing this application, I hereby certify that all information provided is true, complete, and accurate to the best of my knowledge at the time of application.
Name*
Please Type Full Name
Applicant Signature*

Draw your name above with your finger or mouse.
Date Signed*

MonthDayYear
Date

Based on your response, you are not eligible for assistance at this time.

At this time you must be a Collin County resident and/or be a customer of one of our eligible utility service providers.

If you believe this is an error, please contact us at assistance@saminn.org.
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SI Utility Assistance Application