Community Connection Center Assistance Request Form

Community Connection Center

Assistance Request Form

Welcome!

The Nicor Gas Community Connection Center is a free resource that provides information about bill assistance, free energy assessments, housing, food and other resources available for our customers. Please fill out this form completely and we will contact you to discuss how we can help.

We will contact you within 2 business days. If you need further assistance, you can also reach our team at cccinfo@nicorgas.com.

First Name*

Last Name*

Street Address*

City*

ZIP Code*

Phone Number*

Email Address

Referral Source*

How did you learn about the Community Connection Center?

Select

Hardship Type

Select

Are you a Veteran?

Select

Are you a Senior Citizen?(65+yrs)

Select

Assistance Needed*

Please select all that apply

Select

If Other, Please Specify

Preferred Language

Preferred language for return call

Preferred Contact Type

Select

Best Time to be Contacted*

Select

People in Household*

This includes all people living in the household, whether or not they are related

Select

Select Income Range 1