Assistance Form
This form is for Housing, Gas or Electric Assistance. The Utility programs happens once a month on the second Monday of each month. We will help the first 5 callers with the last $50.00 of their bill after the rest has been paid. Bill has to be in applicants name and have a 48 hour cut off notice. Applicants can only apply once ever 2 years.
Name *
Your answer
Address *
Your answer
City
Your answer
State
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Zip
Your answer
Phone number (Home or Cell)
Your answer
Emergency Contact name
Your answer
Emergency Contact Number
Your answer
Email
Your answer
Check Service needed
Staff Only (Disposition)
Your answer
Submit
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