Community Action Agency

Name:

Today's Date:

Phone Number:

Alternate Phone Number:

# of Adults (18+) in the home:

# of children under 18:

Whose name is the bill in?

Does this person live with you currently? Yes No

Is your bill past due? Yes No

Have you received utility assistance from DHHS since October 1? Yes No

Do you have a denial letter from DHHS? Yes No

What is the household gross monthly income?

Shut-Off Date

Shut-Off Amount

Total Amount

Utility Company #2

Shut-Off Date

Shut-Off Amount

Total Amount