Utility Assistance Intake

Utility Assistance Intake

Thank you for submitting your application. Please note that we do not have sufficient funds to accommodate every applicant.Our team will carefully review your application within 3–5 business days. You will receive an update on the next steps via email once the review process is complete.Thank you for your understanding and patience.
Name*
Please type your name in this format "LASTNAME-FIRSTNAME". Write the name in UPPERCASE and separate the last name and first name with an hypen, no spacing.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

Utility Company*
Account Number*
Please verify your Account #
Amount you owe on bill*
*****If over $500 you will not qualify for assistance.*****
Please give us a little information on your crisis( This is the reason you are unable to pay the bill)*

How many in the Household (Including all adults and children)*
0-25,999.9926,000-50,999.9951,000-75,999.99over 76,000.00
Please ensure that you have uploaded all of the items listed on the checklist below; otherwise, your application will not be processed. If all documents are not uploaded, we will proceed to the next in line.
Upload ALL of The Requested Documents Here:*

Please make sure all Documents are clear and legible or we will not process your application for assistance
Cancelof
Please sign here that you understand submission of your application and documents Does NOT guarantee approval of your case. Assistance is based on eligibility and funding.*

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Client Participation Agreement

As a condition of receiving assistance through The Assistance Center of Collin County, all approved clients are required to sign up for and attend all classes directed by their case managerr. Failure to comply with this requirement may result in the denial or termination of assistance.

By signing below, I ackowledge and agree to the following terms:

I will attend all classes and programs assigned by my case manager as a part of my assistance plan.
I understand that attendance is mandatory, and failure to attend may result in the loss of assistance.
If I am unable to attend a scheduled class, I will notify my case manager in advance and discuss alternative options.
I ackowledge that my participation in these classes is essential for my continued elgibility for assistance.
I understand and accept the terms of this agreement and commit to fulfilling this requirement.

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Business Hours ID
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