United Way Utility Assistance Application

United Way Utility Assistance Application

Utility Only Assistance (Water, Electric, and Gas)

Up to $250 per household per year/grant cycle

Eligibility Criteria:

Must meet the 60% County AMI limit, dependent on family size (proof requires last three pay stubs and most recent utility bill for which services are being required (up to 30 days)).
Address must fall within these three zip codes: 28212, 28205, and 28215
Must provide ID (Drivers license or passport are acceptable)

First Name*

Last Name*

Best contact number*

Phone

Best email address*

Home Address*

Application Language*

Select

What utility are you requesting assistance with? (Select all that apply)*

Select

What is the total amount you owe on your electricity bill?

What is the total amount you owe on your Gas bill?

What is the total amount you owe on your Water bill?

Please select your zip code*

Select

Current household income*

How many people are in your household?*

Date of Birth*

Age (based on Date of Birth)*

Select

Gender Identity*

Select

Race/Ethnicity*

Select

Have you sought funding from Crisis Assistance Ministry before requesting EFA?*

Select

Please list reason you were unable to access Crisis Assistance Ministry funds*

File Upload*

Please upload the following:

1). Three most recent paystubs. If you are unemployed, please upload a written document that states that you do not have income.

2). The utility bill(s) you are requesting assistance for

3). ID (Drivers license or passport are acceptable)

***Failure to upload all required documents will result in a denied application***

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