Utility Assistance Self-Service Packet

Funding for the Rental and Mortgage assistance due to COVID has been expended for 2020. Funding and applications will be available in early January 2021.

Visit https://www.mesaaz.gov/government/mesa-cares for more information.

Utility Assistance Self-Service Packet
Required Documentation

Please provide one from each category for EVERYONE in the household, if you have any questions please contact our office. You will not be able to proceed to the application without this documentation.
Proof of Income

EARNED and/or UNEARNED income will be considered in determining eligibility for services. The gross amount of income prior to deductions will be counted unless otherwise specified. Income will be counted as received at the time it is made available to the household.

Proof of income for the past 30 days for everyone in the household-this includes paycheck stubs, current benefit award letters, unemployment paperwork, child support information, school financial aid information.
- Wages- Paycheck stubs
- Self-Employment Income- Business Ledger
- Babysitting/Child Care Income- Signed and dated statement by the person paying for the care
- Housekeeper/Home health aides- Signed and dated statement by the employer
- Social Security- Current benefit award letter
- Unemployment Insurance- Award letter, printout of payments received
- Retirement/Pension Income- Provide written verification from source
- Alimony- Provide court paperwork
- Child support- Provide written verification from the court or Signed and dated statement from the absent parent
- Cash Assistance- Provide written statement by DES
- Gambling Industry- Provide per capital disbursement verification
- Contribution and Complimentary Assistance (cash) - Provide signed and dated statement
Anyone 18 or older with no income will need to provide written documentation from the income source of the last date employed and last date paid, they will need to write a “0 income statement” which is a letter stating they have had no income and they must provide proof of how they have been surviving without any income.
Proof of Income

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Proof of Citizenship

BIRTH CERTIFICATES FOR EVERYONE IN THE HOUSEHOLD

If you were not born in the US, you must give proof of citizenship or legal permanent resident status.

Proof of citizenship - any of the following forms are acceptable, Birth certificate, Passport, passport card, C.I.B., military discharge paperwork or DD-2form, certificate of live birth, recent Social Security income award letter, recent DES nutrition or cash assistance award letter with the name and date of birth.

If born outside of the U.S., please provide proof of or legal permanent resident status or U.S. citizenship. If you have had a name change please include documentation verifying the name change i.e. Court Order, Marriage Certificate.
- Picture I.D. from everyone 18 and older
- Social Security Cards or any legal document with the name and social security number for everyone in the household
Proof of Citizenship

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Utility

Please upload a current copy (with first and last name) of one of the following documents for proof of utility information:
- Utility bill, MPower receipt, or Utility Deposit Letter
Proof of Utility

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Residency/Landlord Verification, W9, TIN

Please upload a current copy (with first and last name) of one of the following documents for proof of residency information:
- Current Lease Agreement, Mortgage Statement or Property tax information
Residency/Landlord Verification, W9, TIN

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Self Service Intake

Applicant Information
Applicant's Name

First NameMiddle InitialLast Name
Social Security Number
Phone Number
Message Number
Email
example@example.com
Are either you or a member of your family an A New Leaf employee?
If Yes, name of employee:
What is the primary language in the household?
If Other, what language?
Gender
Race
Ethnicity
Tribe
Residential Address

Street Address (Street Number, Street Name, Apt. Number)

Street Address Line 2

CityState

Zip Code
Is your Residential Address different than your Mailing Address?
Mailing Address

Street Address (Street Number, Street Name, Apt. Number)

Street Address Line 2

CityState

Zip Code
How many people live in your household (including applicant)?
ex: Just the applicant = 1, Applicant & Spouse or partner = 2
Is there a Veteran in your household?
If Yes, how many?
Is there anyone disabled in your household?
Homeless?
Household Health Insurance

AHCCCSKidsCareMedicareVAThrough EmploymentPrivate / Direct PurchaseTribalNone
What is your Health Plan?
What is your Health Plan ID or Number?
What is your housing type?
What is your family type?
If Other, please explain:
Monthly Utility Cost
Do You live in Subsidized Housing?
What type of home do you live in?
If Other, please explain:
Has the household received rental assistance in the past 12 months?
Date of arrival to the state

MonthDayYear
Date of arrival to the county

MonthDayYear
Is there a Domestic Violence situation in the home?
CONFIDENTIAL: This question will be concealed upon answering YES
Court ordered child support?
Is your household receiving SNAP benefits (food stamps)?
Is your household receiving Unemployment benefits?
Is your household receiving other benefits or income?
If your household is receiving other benefits or income, please explain:
Income Information Notes
What is your marital status?
Crisis Reason
Please document crisis here
Do you make utility payments?
Is your utility payment Past Due, have your received a disconnect notice, or are you low on fuel (very little on M-Power, Propane, etc.)?
HOUSEHOLD MEMBER 1 - Applicant
Applicant Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 2
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 3
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 4
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 5
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 6
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 7
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 8
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 9
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
HOUSEHOLD MEMBER 10
Name

First NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Place of Birth
Last Grade Completed
Health Insurance?
Race
Relationship to Applicant
How many Income Sources does this household member have?
1. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
2. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
3. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
4. Income Source
Name & Number
Frequency
Date Received

MonthDayYear
Gross Amount Received
Total Gross Income Amount
Release of Information
AUTHORITY FOR RELEASE OF INFORMATION:

By signing below, I agree to participate in the Emergency Services Network and utilize MesaCAN as my primary service agency, I authorize MesaCAN and/or delegate agency to contact any source necessary to establish the accuracy of the information given by me and to release or receive information contained on this form and/or in my case file.

APPLICANT’S STATEMENT OF TRUTH:

Under Penalty of perjury and acknowledged by my signature below, I SWEAR or affirm that the statement made regarding the persons in my home, and the income, resources, property and all other items that pertain to my possible eligibility for benefits are TRUE and CORRECT to the best of my knowledge.

Bajo penalidad de perjurio y reconocido por mi firma abajo, yo juro o afirmo que las declaraciones hechas en cuanto a las personas en mi hogar, y los ingresos, los recursos, propiedad y todas cosas demás que pertenecen a mi elegibilidad posible por beneficios son verdaderos y ciertas según mi leal entender y saber.
Applicant Name

First NameLast Name
Signature Date

MonthDayYear
Applicant Signature

Clear

STAFF USE ONLY

ANY CHANGES MAY PREVENT YOUR APPLICATION FROM BEING PROCESSED
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CM REVIEW

Application Voucher

Case Manager Review
Application Status
Review Date

MonthDayYear
Case Manager: Enter your username
Case Manager First Name
Case Manager Last Name
Case Manager Email
Additional Documents

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Application Notes
Requirements Checklist
Utilities Requirements Checklist
Rent Requirements Checklist
What type of assistance has been requested?

City of MesaSRPSouthwest GasPrimary RentalSecondary Rental

City of Mesa Voucher
com_manual_voucher_nbr
Use this voucher number, if available. Otherwise, use the voucher number in the next field.
Account Number
Is this account under a different name than the applicant?

YesNo
Alternate Billing Name
Make sure they complete the ROI
Amount Approved
Status
Status Date

MonthDayYear
Denial Reason
Voucher Comments
Case Manager Signature

Clear
Case Manager Signature Date

MonthDayYear
Finance Review
Finance Determination
Finance Reviewer: Enter your username
Finance First Name
Finance Last Name
Finance Signature

Clear
Finance Signature Date

MonthDayYear
Payment Status
Payment Amount
Date Paid

MonthDayYear

SRP Voucher
srp_manual_voucher_nbr
Use this voucher number, if available. Otherwise, use the voucher number in the next field.
Account Number
Is this account under a different name than the applicant?

YesNo
Alternate Billing Name
Make sure they complete the ROI
Amount Approved
Status
Status Date

MonthDayYear
Denial Reason
Voucher Comments
Case Manager Signature

Clear
Case Manager Signature Date

MonthDayYear
Finance Review
Finance Determination
Finance Reviewer: Enter your username
Finance First Name
Finance Last Name
Finance Signature

Clear
Finance Signature Date

MonthDayYear
Payment Status
Payment Amount
Date Paid

MonthDayYear

Southwest Gas Voucher
swg_manual_voucher_nbr
Use this voucher number, if available. Otherwise, use the voucher number in the next field.
Account Number
Is this account under a different name than the applicant?

YesNo
Alternate Billing Name
Make sure they complete the ROI
Amount Approved
Status
Status Date

MonthDayYear
Denial Reason
Voucher Comments
Case Manager Signature

Clear
Case Manager Signature Date

MonthDayYear
Finance Review
Finance Determination
Finance Reviewer: Enter your username
Finance First Name
Finance Last Name
Finance Signature

Clear
Finance Signature Date

MonthDayYear
Payment Status
Payment Amount
Date Paid

MonthDayYear

Primary Rental Voucher
prent_manual_voucher_nbr
Use this voucher number, if available. Otherwise, use the voucher number in the next field.
Account Number
Is this account under a different name than the applicant?

YesNo
Alternate Billing Name
Make sure they complete the ROI
Amount Approved
Status
Status Date

MonthDayYear
Denial Reason
Voucher Comments
Case Manager Signature

Clear
Case Manager Signature Date

MonthDayYear
Finance Review
Finance Determination
Finance Reviewer: Enter your username
Finance First Name
Finance Last Name
Finance Signature

Clear
Finance Signature Date

MonthDayYear
Payment Status
Payment Amount
Date Paid

MonthDayYear

Secondary Rental Voucher
srent_manual_voucher_nbr
Use this voucher number, if available. Otherwise, use the voucher number in the next field.
Account Number
Is this account under a different name than the applicant?

YesNo
Alternate Billing Name
Make sure they complete the ROI
Amount Approved
Status
Status Date

MonthDayYear
Denial Reason
Voucher Comments
Case Manager Signature

Clear
Case Manager Signature Date

MonthDayYear
Finance Review
Finance Determination
Finance Reviewer: Enter your username
Finance First Name
Finance Last Name
Finance Signature

Clear
Finance Signature Date

MonthDayYear
Payment Status
Payment Amount
Date Paid

MonthDayYear
Should be Empty:

Utility Assistance Self-Service Packet

Required Documentation

Self Service Intake

HOUSEHOLD MEMBER 1 - Applicant

HOUSEHOLD MEMBER 2

HOUSEHOLD MEMBER 3

HOUSEHOLD MEMBER 4

HOUSEHOLD MEMBER 5

HOUSEHOLD MEMBER 6

HOUSEHOLD MEMBER 7

HOUSEHOLD MEMBER 8

HOUSEHOLD MEMBER 9

HOUSEHOLD MEMBER 10

Release of Information

STAFF USE ONLY

CM REVIEW

Finance Review

Finance Review

Finance Review

Finance Review

Finance Review