COVID-19 Utility Assistance Request Form

Head of Household Information

Head of Household First Name: *

Head of Household Last Name: *

Head of Household Middle Initial: *

Date of Birth *

Social Security Number *

Veteran Status *

Ethnicity *

Address *

City

State/Province

Zip/Postal

Country

Who is your utilities service provider: *

Phone Number *

E-Mail *

Other Adults in Household

Adult #2: Last, First, and Middle Initial

Relation to Head of Household: *

Date of Birth

Social Security Number

Veteran Status

Ethinicity

Phone Number

Please provide information on any additional adults in the household:

First Name, Last Name, Middle Initial, Date of Birth, Social Security Number, & Ethnicity

Children in the Household

Child #1: Last, First, and Middle Initial *

Relation to Head of Household: *

Date of Birth *

Social Security Number *

Ethnicity *

Child #2: Last, First, and Middle Initial

Relation to Head of Household:

Child #2: Date of Birth

Child #2: Social Security Number

Child #2: Ethnicity

Child #3: Last, First, and Middle Initial

Relation to Head of Household:

Child #3: Date of Birth

Child #3: Social Security Number

Child #3: Ethnicity

Child #4: Last, First, and Middle Initial

Relation to Head of Household:

Child #4: Date of Birth

Child #4: Social Security Number

Child #4: Ethnicity

Please provide information on any additional children in the household:

First Name, Last Name, Middle Initial, Date of Birth, Social Security Number, & Ethnicity

Assistance Needed

Reason for Requested Assistance *Must be able to verify reason given* *

Reduction of Hours

Caring for self or immediately family member diagnosed with COVID-19

Loss of Job or Income

Other

Please Explain what the Loss of Job or Income or Reduction of Hours is due to: *

Who is your utilities service provider you are need assistance with? *

How much assistance are you requesting? *

What month are you requesting assistance for? *

March

April

May

How did you hear about us? *