Senior Citizen Utility Assistance Application
Applicant Information
Full Name
Date of Birth
Social Security Number
Address
City
State
ZIP Code
Phone Number
Email Address
Household Information
Number of People in Household
Monthly Household Income
Income Sources
Utility Information
Type of Utility Assistance Needed
Electricity
Gas
Water
Other
Utility Account Number
Utility Provider
Reason for Assistance Request
Certification
I certify that the above information is true and complete.