COVID-19 Utility Assistance Application Form

COVID-19 Utility Assistance Application

This Caring For Others program is specifically designed for metro Atlanta families who's income has been adversely effected by COVID-19 i.e., loss of job, furloughed, or illness. This program is specifically designed to assist with a select monthly utility bill only (i.e., either electric, gas, or water only)
General Information
Name:*

PrefixFirst NameLast Name
Street address:*
Street address line 2:
City:*
State*
Zip Code:*
Phone number:*
Email address:
Sex:*

MaleFemale
Race:*

WhiteAfrican AmericanHispanicAsianOther
Marital Status:*

MarriedSingleDivorcedWidowed
Date of Birth:*

MonthDayYear
# of Individuals in the Household:*
Employment Information
Current/Last Employer*
Please enter the name of your current or last employer
Street address:*
State*
City:*
Zip Code:*
Current/Last Job Title:*
Please enter the position you hold/held
Supervisor's Name:*
Employer Phone Number

Area CodePhone Number
Current/Last Employment Type:*

Full TimePart Time
Hourly or Salary?:*

HourlySalary
Monthly wages/salary you were receiving before layoff/furlough/reduction-in-hours or coronavirus illness:*
Please enter numbers only
Are you currently laid-off, furloughed or experiencing reduction-in-hours as a result of the COVID-19 pandemic?:*

Yes, I've been laid-offYes, I've been furloughedNo, I'm still employed and working but hours have been reducedOther
Date laid-off/furloughed/hours reduced or coronavirus illness determined

MonthDayYear
Note about qualifying:
The Caring For Others COVID-19 Utility Assistance Program is designed for individuals and families who's income has been directly affected by COVID-19 i.e., the specific employer has laid them off, furloughed, reduced their hours or they've fallen ill due to contracting COVID-19. If you do not fall into one of these three categories as a result of COVID-19, then you are not qualified for this program.
Financial Information
The following documents are required to be submitted for review:
- Last pay stub before layoff or furlough
- Letter approving or denying unemployment compensation (if applicable)
- Latest mortgage statement or rental agreement
These documents can be uploaded through the link in this section or, if scheduled for an interview, brought with you for verification. The application is incomplete without these documents.
Please click on the button below to upload the required documents. *

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Have you applied or are currently receiving unemployment compensation?:*

Yes, I'm receiving unemployment compensationYes, I've applied but haven't received compensation yetNo, I haven't applied and am not receiving unemployment compensation
Current Monthly Income
Monthly amount of unemployment compensation you're currently receiving:*
Please enter numbers only; if none, enter 0
Monthly wages/salary you're currently receiving:*
Please enter numbers only; if none, enter 0
Other monthly income you're currently receiving:*
Please enter numbers only; if none, enter 0. Other income includes alimony, child support, pension, etc.
Total Current Monthly Income
Please provide documentation of income*

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For example: pay stub, unemployment letter, etc. Cancelof
Current Monthly Expenses
Monthly Rent/Mortgage:*
Please enter numbers only; if none, enter 0
Monthly Food:*
Please enter numbers only; if none, enter 0
Monthly Electric & Gas:*
Please enter numbers only; if none, enter 0
Monthly Car payment & Insurance:*
Please enter numbers only; if none, enter 0
Monthly Telephone, Cell, Internet & Cable:*
Please enter numbers only; if none, enter 0
Other Monthly Expenses (e.g., public transportation, child care, water, etc.):*
Please enter numbers only; if none, enter 0
Total Current Monthly Expenses*
Utility Assistance Request

The eligible utilities covered under the CFO Utility Assistance Program are:
- Electric
- Gas
- Water
Cable, Internet, Cell, and/or phone bills are not eligible for coverage under this program.

Only one specific monthly utility bill will be covered under this program up to $250. Please select the type of utility bill from the menu below and enter the amount of the assistance requested. This should not exceed the amount of the bill. The maximum assistance that can be provided is $250. Finally, please upload a jpeg, png or pdf of the specific utility bill you wish to have covered by clicking on the button below.
Type of Utility Bill*

ElectricGasWater
Amount of assistance requested:*
Please enter numbers only; maximum assistance is $250
Please upload the specific utility bill related to your request:*

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JPEG, PNG or PDF are accepted Cancelof
Certification
By submitting this application, I affirm that the above information is true and correct to the best of my knowledge. I understand if the information I give is determined to be false, the result will be denial of financial assistance, and I will be responsible for and expected to pay for services provided.
Should be Empty: