Utility Assistance Application1

utility assistance application
click on question mark(?) for additional information

* Indicates required field

Applicant Name(must be head of the household) *

First

Last

Email *

Address *

City *

Zip Code *

Contact Phone Number *

#Members in your household *

Choose *

Female Male Other

Your Age *

Employment Status(Head of the household) *

Education Attainment *

Choose type of assistance needed *

Electricity Water Gas

Name of Utility Company *

Account Number *

Utility Company Phone Number: *

Amount Requested *

Have you received assistance from United Way in the past 12 months? *

Have you applied to another organization? *

Yes No

If Yes, Please provide the name of organization(United Way will verify information either way). *

Amount of Annual Household Income(head of the household)("0" if none) *

Upload the most current tax return(head of the household) *

Max file size: 20MB

Upload the bill in question *

Max file size: 20MB

Select One- Optional *

Tell us, why are you requesting assistance? *

Special thanks to the following community partners for its generous donation:

Thank you for applying to United Way of Pinal County programs fund.
Don't forget to click submit.

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