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Community Action Agency

Utility Intake Questions

Does this person live with you currently?
Do any adults in the household have income?
Do you rent or own your home?
Do you receive a Housing Choice Voucher (formerly sec. 8) or have subsidized housing?
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 received additional utility assistance from DHHS, True North or Salvation Army?

Utility Information:

Additional Notes: