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Community Action Agency

Utility Intake Questions

Does this person live with you currently?
Have you made a personal payment of at least $50 on this bill within the last six months?
Do you have a shut-off notice?
Have you applied for utility assistance from DHHS since October 1? Do you have a denial letter from DHHS?
Have you received utility assistance from DHHS since October 1?

Utility Information:

Additional Notes: