COVID-19 Utility Assistance

COVID-19 Utility Assistance Request Form

Head of Household Information

Veteran *
Hispanic or Latino *

Other Adult in Household

Veteran *
Hispanic or Latino *
For each additional adult in the household please include: First Name, Middle Initial, Last Name, Date of Birth, Social Security Number, Ethnicity, Relationship to Head of Household

Children in the Household

For each additional child in the household please include: First Name, Middle Initial, Last Name, Date of Birth, Social Security Number, Ethnicity, Relationship to Head of Household

Assistance Needed

Reason for Requested Assistance *Must be able to verify reason given* *
i.e. Business closed due to stay in place order, resulting in loss of income.
What month are you requesting assistance for? *
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