ALICE Assistance Request Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
County of Residence
*
Hancock
Brooke
Ohio
Marshall
Wetzel
Tyler
Belmont
Total Number in Household
*
Number of Dependents and Their Ages
*
Please explain if above 18-years-old, i.e. still in school
Bill Needing to be Paid (Gas & Electric Only)
*
Bill Amount
*
Utility Account Number
*
Request Details
*
Brief narrative of why the assistance is needed
Other Agency Participation
*
Are any other agencies helping with this bill? If so, please list.
Monthly Income for Household
*
Source of Income
*
Upload Pay Stub
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Bills (Attach Copies) - Please Include ALL Bills
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Bills (Attach Copies) - Please Include ALL Bills
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Bills (Attach Copies) - Please Include ALL Bills
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Bills (Attach Copies) - Please Include ALL Bills
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Monthly Bills (Attach Copies) - Please Include ALL Bills
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Federal or State Benefits Received (Please check all that apply)
*
SNAP
Medicaid
TANF
I verify that the information above is accurate and understand that this is a one time assistance payment.
Continue
Continue
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