Urgent Utility Bill Assistance Application
Full Name
Street Address
City
State
ZIP Code
Phone Number
Email Address
Utility Information
Type of Utility Bill
Electricity
Water
Gas
Other
Utility Account Number
Utility Provider Name
Amount Due ($)
Due Date
Have you received a disconnection notice?
Yes
No
Assistance Details
Amount Requested for Assistance ($)
Reason for Assistance
Current Income Source(s)
Household Size
Additional Information