Utility Assistance – 2Fish5loaves.org

Name
Primary Phone Number
Secondary Phone Number
Mailing Address
City
State
Zip
Street Address if different than mailing address
Email Address
Social Security Number
Do You Live In a:
Apartment
- Apartment
- Multi Family
- Single Family Home
- Mobile Home
Are you a:
Renter
- Renter
- Roomer
- Boarder
- Home Owner
*If you rent: Is your rent reduced through help from HUD or Subsidized Housing (Section 8)?
Yes
- Yes
- No
RENTERS ONLY Are your utilities included in the rent?
Yes
- Yes
- No
Landlord’s Name/Apartment Complex:
Landlord’s Mailing Address:
City:
State:
Zip
Landlord’s Phone Number:
Land Lord Email Address:
Total # in Household
# of Children (age 0-17)
# of Adults (age 18-64)
REASON FOR EMERGENCY Utility ASSISTANCE:
# of Senior Adults (age 65 +)
HOUSEHOLD MONTHLY GROSS INCOME:
Copy of your driver’s license, Copy of utility bill and late notice/shut off notice
Drop files here or