Request Utility Assistance

First Name*

Last Name*

Gender*

Male

Female

Are you a Veteran?*

Yes

No

Marital Status*

Married

Single

Divorced

Widow

Address*

Street Address City State Zip Code

Phone*

Email*

Who referred you to us? (church, online, other agency...)

Other adults living in the household:

Adult #2 - First Name:

Adult #2 - Last Name:

Gender:

Male

Female

Relationship to Adult #1

Monthly Household Income*

USD

Adult #1 Job Description*

Adult #2 Job Description

Monthly Rent or Mortgage Payment*

USD

Section 8 or Housing Assistance

Yes

No

How many children live in the home?

Monthly Food Stamps Received*

USD

Other Income Amount*

USD

Sources of Other Income (Child Support, Family Support, etc)

Briefly describe how COVID-19 has created your need for Utility Assistance*

Current Utility Bill
You will be required to upload a copy of the entire bill.

Upload

Has Shepherds of Love Ministries assisted you previously?

No

Yes

I have answered all questions to the best of my ability and knowledge. I understand that falsifying any information in this application may disqualify me from receiving ANY Utility Assistance from Shepherds of Love Ministries, Inc. My application and interview will not guarantee assistance, only consideration. Shepherds of Love Ministries Inc. will maintain strict confidentiality of all information provided.*

Yes - I wish to be contacted for an interview. My application and interview WILL NOT guarantee assistance. I authorize and understand this information. An answer of YES is equivalent to my signature.

No - I do not authorize or understand this information. An answer of NO is a refusal of my signature, I withdraw my request to be considered for utility assistance at this time.

Additional Comments/Questions