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EMERGENCY UTILITY ASSISTANCE
ON LINE
ELIGIBILITY INTAKE FORM
DC WATER
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Name of Applicant
Please select
APPLYING FOR DC WATER ASSISTANCE
PLEASE BE MINDFUL THIS ASSISTANCE IS ONE TIME IN THE AMOUNT OF $350
USD
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USD
If you answered yes: please provide which organizations you received assistance from - Month/Year & Which Utility:
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CURRENT EMPLOYMENT STATUS
(PLEASE CHECK ONE)
INCOME PER YEAR - (INCLUDE EVERYONE WORKING IN THE HOUSEHOLD)
USD
PLEASE MAKE SURE YOU MEET THE INCOME GUILDELINES LISTED BELOW
FEDERAL INCOME ELIGIBILITY FOR GWUL/DC WATER EMERGENCY ASSISTANCE PROGRAM
Household Size
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Maximum Annual Income
$49,814
$65,141
$80,469
$95,797
$111,124
$126,454
$129,325
$132,199
DOCUMENTS REQUIRED TO COMPLETE APPLICATION (Upload on Page 6)
1. Photo ID
2. Social Security Cards - (For everyone 18 and over)
3. Birth Certificates - (For everyone 17 and under)
4. Proof of Income
5. Current Bill
6. Proof of Residence - (Lease or Mortgage Statement)
7. Letter of Hardship (Stating circumstance for needing assistance)
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INTAKE - I
SPLASH PROGRAM
"SERVING PEOPLE BY LENDING A SUPPORTING HAND"
CHECK DOCUMENTATION YOU'RE PROVIDING BELOW
Name of Applicant:
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INTAKE - II
SPLASH PROGRAM
"SERVING PEOPLE BY LENDING A SUPPORTING HAND"
CLIENT INFORMATION
Name of Applicant:
Family Size
Click "add more" to add as many household members as needed
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SPLASH PROGRAM
"SERVING PEOPLE BY LENDING A SUPPORTING HAND"
FINANCIAL NEED
Name of Applicant:
Utility Information
Financial Needs of Applicant
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USD
USD
USD
USD
All information provided in this application is true and correct to the best of my knowledge. I understand that false statements of information could render my application invalid for funding consideration. I also understand that completion of this application does not guarantee the granting of funds. I authorize the GWUL and DC Water/SPLASH representative to gather any necessary information from agencies of individuals involved in my case to qualify me for funds.
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Upload Your Documents Here In Order To Submit Your Application
Please upload in doc. docx, jpeg, png, or pdf format.
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