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?
Who is your utility provider?

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

Other
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?

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
2 digit month, 2 digit day, 4 digit year
Applicant Sex
Applicant Race
Are you Hispanic or Latino?

Required Documents

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

Driver License or ID, US Passport
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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 that failure to submit all required documentation or fully answer all application questions will result in an incomplete application.
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 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.
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
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applicant Signature

Draw your name above with your finger or mouse.
Based on the information you provided, you are not eligible for assistance at this time.

To qualify for assistance, you must live in Collin County and/or receive utility service from one of our eligible providers.

If your utility provider is listed as an eligible provider but you received this message, it means the funding available for that provider has been used. You are welcome to check our website and apply again in the future if additional funding becomes available for your provider.

If you believe you received this message in error, please contact us at assistance@saminn.org.
Should be Empty:

SI Utility Assistance Application

SI Utility Assistance Application

Applicant Information

Household Information

Required Documents

The Samaritan Inn Agreements