Utility Bill Assistance Application

Utility Bill Assistance Application

Apply here to receive help with your utility bills
Full Name

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

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Household size
We will follow up with you within 2 business days. If you do not receive a confirmation with your application number, please contact us to check on the status of your application or to confirm that all required documents have been received.
Date of Birth

MonthDayYear
Please list everyone in your household (including date of birth) and their income
Proof of Social Security/ ITIN

Cancelof
Upload Supporting Documents (e.g., utility bills, proof of hardship)

Cancelof
I agree that my information may be submitted to the appropriate agencies to determine if I qualify for utility bill assistance. I understand that all required documents must be provided before the application process can begin. I also understand that submitting an application does not guarantee assistance, and I will continue making payments toward my bill whenever possible.
Should be Empty: