PROJECT U RELIEF, INC. APPLICATION FORM

Personal Information

Applicant First Name *

Applicant Last Name *

Address 1 *

City *

State *

Zip Code *

Phone *

Email Address *

Services Applying For *

Household Information: *

Head of Household

+-

All Other Members

+-

VOLUNTARY SELF-IDENTIFICATION OF GENDER, VETERAN STATUS, ETHNICITY AND RACE *

QUESTIONNAIRE

1. What is your initial request for general assistance? Please provide the balance for each utility bill that you are requesting assistance for UTILITIES: Electric Gas Water *

2. What created the situation that brought you to Project Utilities Relief to request assistance? Please explain your situation. (COVID-19 Loss of Employment Emergency Disability Other *

3. How did you hear about our program? If other, please explain how you heard about our program *

4. Are you currently receiving any assistance through another agency? If Yes, please list the name of the agency: *

5. Work status? Employment Self-Employed Unemployed Other:

6. Income status? (Employment check, self-employment, unemployment benefits, social security, TANF, Child Support SSI/ SSD/VA Benefits, Other)

MONTHLY FINANCIAL INFORMATION To include: Wages, salary, overtime, hazard pay, commissions, fees, tips, bonuses (before payroll deductions) Social Security (INCLUDE disability/Supplemental; INCLUDE gross amount prior to any Medicare premiums) Other income *

Current Total:

0.00

PROJECT UTILITIES RELIEF UTILITY ASSISTANCE APPLICATION

APPLICANT CERTIFICATION:

I, , certify under penalty of perjury that the above information is complete and accurate to the best of
my knowledge. I understand that Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony
and assistance can be terminated for knowingly and willingly making a false or fraudulent statement to a department
or agency working for the United States Government. I agree to provide any additional documentation required by
the program administrator to document my/our household income.

HEAD OF HOUSEHOLD (Printed Name)

Signature Date:

Other Adult Household Members

Printed Name:

Signature Date:

Martial status:	Married
Divorced	Widowed
Seperated	Common law
Single