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utility assistance application
click on question mark(?) for additional information
*
Indicates required field
Applicant Name(must be head of the household)
*
First
Last
Please type your official name. Specially if applying for utility assistance
Email
*
Address
*
City
*
Zip Code
*
Contact Phone Number
*
The number you would like us to call you.
#Members in your household
*
1-2
3-5
6-8
Choose
*
Female
Male
Other
Your Age
*
Age of the applicant
Employment Status(Head of the household)
*
Employed
Unemployed
Retired
This is only for the head of the household or individual requesting support.
Education Attainment
*
Less than High School
High School Diploma or GED
Trade School or Certifications
Associate Degree
Bachelor Degree
Other
We ask to identify other programs you can qualify for.
Choose type of assistance needed
*
Electricity
Water
Gas
Name of Utility Company
*
Account Number
*
If you are qualified, we will use the account number to directly call the utility company and pay your bill.
Utility Company Phone 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?
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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)
*
Combined household income. Everyone in the household
Upload the most current tax return(head of the household)
*
Max file size: 20MB
This is used to verify your income for the approval process.
Upload the bill in question
*
Max file size: 20MB
Select One- Optional
*
White
Hispanic/Latino
Black/African American
American Indian
Other/Multi-Racial
Tell us, why are you requesting assistance?
*
Share your current situation and why United Way support is important.
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.
Submit
Home
Programs
DONATE
Contact us
Apply for Help
EDUCATION, SCHOLARSHIPS, AND CHILD CARE
FREE TAX PREPARATION