We do not guarantee your benefit will be processed and paid before the date the bill is due. Emergency Financial Assistance Intake Form. EOA WATER UTILITY ASSISTANCE APPLICATION Economic Opportunity Agency of Washington County 614 E. Emma Ave., Ste. For other COVID-19 related operational changes, view our blog post. ELIGIBILITY FOR WATER UTILITY ASSISTANCE (One-time Payment of Up to $100 Paid Directly to Water Utility Supplier) Proof of Income for Previous Month for all Household Members If your household’s combined income for the 30 days prior to application (gross income, before taxes are deducted) is at or below 200% of the federal poverty (up from 150% last year), level as shown in the chart below, you may be eligible to receive assistance. In order to be considered for this assistance, you must complete, sign and submit the following Customer Intake Form to Fairfax Water (or complete the Intake Form by phone) on or before . Energy Assistance Connect with us: www.cedaorg.net (800) 571-CEDA (2332) Energy Assistance Program Eligibility Requirements Income Guidelines LIHEAP Application Dates: Remote Intake began April 20, 2020. This type of assistance is a one-time benefit per household per program not to exceed $500. The intention of this document is to be used in phone interviews or when taking information without a computer present.) To request an application via mail or email please contact the Utility Assistance Hotline at 713-590-2327 or the United Way of Greater Houston Helpline at 2-1-1 or 713-957-4357. Please write legibly. Until your application is processed, you will be responsible for your utility bills and any late fees that occur. COVID-19 ASSISTANCE For Rental Assistance CLICK HERE. 2021 Community Services Intake Application . I don't have enough food. ... ALL APPLICATIONS REQUIRE PROOF OF INCOME FOR ALL HOUSHOLD MEMBERS 18 YEARS OLD AND OLDER WITHIN THE LAST 30 DAYS FROM DATE OF SUBMISSION OF THE APPLICATION. The assistance … Income – Must submit proof of current income for the past 30 days for all household members eighteen (18) years of age and older. CAAGKC Intake Application (Family Intake Assessment and Referral Form) *required for all applications To be eligible – must meet income guidelines. Family Assistance Program Utility Assistance Form APS Extranet Agreement - Exhibit C APS Customer Consent Form I hereby consent to and authorize __CPLC_____ ... and to use such information in connection with my application for financial assistance on this date. Date: APPLICANT INFORMATION First Name ... What is your temporary financial crisis in addition to high utility costs? Once the application is processed, you will be notified i f you qualify for assistance. Application Number: Application Received By: Date/Time Application Received: What type of utility assistance are you requesting? If you are eligible to receive assistance for cooling costs you should apply for this benefit at the same time that you apply for help with heating costs. Subsequent applications for this type of assistance during the same program, by the same household or member of a household, having received a crisis benefit, will be denied. ☐Yes ☐ No Primary Applicant First Name: Middle Name Last Name Social Security Number: Date of Birth Gender Month/Day/Year If you are unable to attach documents, copies will need to be provided at your intake appointment. We are here to help. We can help! December 1, 2021 . Assistance is provided on a first-come, first-served basis so applicants are encouraged to apply as soon as they are eligible. Utility Arrearage Assistance . Please type or use BLUE ink. The eligibility requirements are as follows: * Must be a resident of Harris County * Must meet the U.S. Department of Health and Human Services Income Guidelines ... UTILITY BILL (Energy assistance … Rental/Mortgage and Utility Assistance Checklist All documents must be completed and submitted to CAAGKC before the application can be processed. CSBG Customer Intake Application Program Name Application Date ☐ Emergency Services ☐ Utility Assistance Month/ Day/Year Have you already received a 3-day or eviction notice from your landlord? Application Number: Application Received By: Date/Time Application Received: 1. Utility Arrearage Assistance Customer Intake Form (ONLY active Newport News Waterworks customers need apply. CARES Act assistance application may provide assistance for bills dated March 1, 2020 to the present, and may not be used for past due amounts prior to this time period. UTILITY ASSISTANCE PROGRAMS For everyone’s protection, we are not conducting face to face appointments at this time. To apply for Family Assistance, you MUST provide copies of (1) household income, (2) current utility bill(s), and (3) identification of household members. ENERGY BILL ASSISTANCE INTAKE FORM. Form #1: Utility Assistance Checklist (signature needed) Form #2: Client Intake Form #3: Staff Screening CRF UTILITY ASSISTANCE INTAKE APPLICATION . Before completing the application, please read and respond to the statements below. It may take up to 30 days to process your utility assistance application. For your convenience, we now have an electronic version of this application available at www.sanantonio.gov/DHSutilitythat can be completed from a smart phone or tablet with a camera. Applications will Incomplete application packets will result in an “Unable to Assist” determination. Utility Arrearage Assistance Customer Intake Form. Helps with primary heating sources like electric, natural gas, LP gas, kerosene and wood. I hereby authorize my energy provider This application is ONLY for residential accounts! 2.I hereby authorize RPU to release information regarding my bills past and future, to CAP. CHN is the entry point to access rental assistance, a broad array of housing, utility assistance, and referral resources, which you will be screened for. Complete this form, print, sign (pdf signatures acceptable),or download , and email to wwcs@nnva.gov or place in drop box outside City Center, 700 Town Center Dr. (*Assistance will be available until funds have been depleted*) 3.I certify that I am temporarily unable to pay my energy bill(s). ONLY Portsmouth Utilities customers need apply. The following program benefits are currently available to … Crisis Assistance — is available for eligible households during designated application periods. It is your responsibility to continue to pay and/or make payment arrangements with your utility company until eligibility it determined. Utility Assistance. Regular application period January – March is open to anyone meeting the income guidelines. You will be under no obligation to participate in any programs we recommend. M401 Springdale, AR 72764 (479)872-7479. If you qualify for assistance, an appointment will be scheduled with a Case Manager, if needed. Until your application is processed, you are responsible for your utility bills and any late fees applied. The average processing time for assistance is 28 business days. 1.I hereby authorize the Community Action Partnership (CAP) to examine all employment, income, utility, and o ther records pertinent to my application for energy assistance. All assistance is subject to the availability of funds. RENT AND/OR UTILITY ASSISTANCE DOCUMENT CHECKLIST _____ Please complete the attached application and submit copies of the following documents with your completed application to rentandutility@maikerhp.org or postal mail to Maiker Housing Partners 3030 W 71st Ave, suite 1000 Westminster CO 80229: Please review PREPARED BY: DATE: APPLICANT INFORMATION First Name: Last Name: Email Address: Does not require a past due bill and can help create a credit balance. Customer Intake Form . Please note that a signed, completed intake application and all required documents must be submitted in order for your application to be processed in a timely manner. You may take pictures of required documents and upload them with this application. If you are not using a smart phone or tablet, you can download the printable paper application … The average processing time is 28 business days from the date your completed application is received. APPLICANT INFORMATION - TO BE COMPLETED BY APPLICANT: (Head of Household) Full Name: Current Address: Apt# City, State Zip: Daytime phone: Mobile Phone: Once application is processed, you will be notified via mail or email. Mortgage, Association, and/or Utility Assistance INTAKE APPLICATION This Section will be completed by County staff. Either: a. Upload scanned application and documents: https://ewashtenaw.sharefile.com/r-r5d3d2d9362d4d178 b. Fax all of the following forms and household documentation in the order below to 734-274-4905. To apply for utility assistance you must provide COPIES of (1) household income, (2) current utility bill(s), (3) identification for household members and (4) proof of citizenship for ALL household members. All blanks must be completed or have N/A written in. Emergency Financial Assistance Intake Form. RENTAL AND UTILITIES ASSISTANCE INTAKE APPLICATION INSTRUCTIONS FOR APPLICATION General Instructions Read the instructions for this application. To relieve the burden on our phone system we have added an online option to request assistance. Complete this form, print, sign (pdf signatures acceptable), and place in Public Utilities drop box located outside of City Hall (801 Crawford Street) or email portsmouthutilityrelief@portsmouthva.gov. The COVID Crisis Rental Assistance program was established in response to a Public Health Emergency due to the COVID-19 pandemic and the related evictions and utility turn-offs. Do not use pencil or other colors of ink. By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. A submitted application is not a guarantee of financial assistance. Enclosed you will ˜nd an intake application for utility assistance and instructions to help you complete your application. Incomplete applications are unable to be processed until fully completed. ENERGY BILL ASSISTANCE INTAKE FORM (All information needs to be entered into the NJ SHARES system to be a valid application. Please remember this form is for other help not rent and utility assistance. TCOG is not responsible for interruption of services or fees. Energy Assistance Application-Vision Impaired ... proof of identity for the individual listed on the utility bill is required along with written authorization for the applicant to apply and; ... Intake Sites will also provide assistance in completing and mailing applications to the EAP Office. Rental & Utility Assistance Application Thank you for contacting Mesa CARES. I acknowledge that I am the customer of record on my energy account(s) listed on this application. o~¼9~ñÃÍÝýÁ¢Í»ÏðpÇ#~z#Sñ¿Aüë?Mü)±PRAuvuv¡u6©uìЦ8â cª¯³ë¯³k®³ë¬³+³««³ë«³+¬15ÖÏ´ä¡. Instead of going into an agency, a HEAP Intake Specialist will contact you on the… with responses showing that you meet the customer eligibility criteria set forth above. The application period is from October 1 through June 30. (u;Ù°¦doÁ¾fÕö©èMË5Þ¯hɦî U©v(áô9-⣣ié¢ûª©Ë´.kì~6Í_z5ÓHMO4lõ°päÝ J«0M»F2WÁ}¤êªJ ²ÛggàýtÊÐË´ëýIñåß«Ü!ÃXè½ÐFÝÜܵÅKåôìè»Ó Òå³ùu ¼2Ф. Applications are processed in the order it is received and by priority rating scale. Fill out the application in its entirety and send all documents requested for expedited processing. FAD Utility Assistance Intake Application requires 2 signatures, and CPS form requires 1 signature.
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