Utility Bill Financial Assistance Application Form
Applicant Information
Full Name
Date of Birth
Address
City
State
ZIP Code
Phone
Email
Household Information
Number of People in Household
Number of Dependents
Utility Information
Type of Utility
Electric
Water
Gas
Other
Utility Account Number
Utility Company Name
Amount Owed
Income Information
Primary Source of Income
Monthly Household Income
Assistance Details
Reason for Requesting Assistance
Have you received utility assistance before?
Yes
No
Additional Information