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EMERGENCY UTILITY ASSISTANCE
ON LINE
ELIGIBILITY INTAKE FORM
PEPCO/GAS
Application Date
MM
/
DD
/
YYYY
Name of Applicant
Address
Ward
Please select
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Please select
Zip Code
Home Phone
Work Phone
Cell Phone
Email Address
APPLYING FOR PEPCO/GAS ASSISTANCE
PLEASE BE MINDFUL THIS ASSISTANCE IS ONE TIME IN THE AMOUNT OF $500
THINK ABOUT WHICH UTILITY IS PRIORITY TO KEEP YOU FROM BEING DISCONNECTED
1. PEPCO:
USD
Past Due Balance
USD
Current Balance
USD
2. GAS:
USD
Past Due Balance
USD
Current Balance
USD
Have you applied for Utility Assistance from other organizations in the past (3) years?
Yes
No
If you answered yes: please provide which organizations you received assistance from - Month/Year & Which Utility:
1.
2.
3.
4.
5.
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CURRENT EMPLOYMENT STATUS
(PLEASE CHECK ONE)
Please check one:
Employed
Unemployed
If employed, what is the name of your employer?
If unemployed, how long and what is the reason?
INCOME PER YEAR - (INCLUDE EVERYONE WORKING IN THE HOUSEHOLD)
Income Per Year
USD
Total Number of Household Members
Total Number of Children in Household (18 and Under)
Total Number of Seniors in Household (65 and Under)
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
$57,571
$75,286
$93,001
$110,715
$128,429
$146,144
$149,465
$152,787
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
PEPCO/GAS PROGRAM
CHECK DOCUMENTATION YOU'RE PROVIDING BELOW
Name of Applicant:
PICTURE IDENTIFICATION
Driver's License
Non-Driver's ID
Food Stamp ID
Passport
Other
FAMILY ELIGIBILITY
Birth Certificates
School Documents
Court Papers
Tax Documents
Adoption Papers
Other
PROOF OF RESIDENCY:
Utility Bill
Lease
Mortgage Payment Booklet
Rent Teceipts
Notarized Letter from Landlord
Deed
Other
PROOF OF EMERGENCY:
Court Summons/Judgement
Disconnection/Interruption Notice Utility Co.
Other
PROOF OF REASON FOR DELINQUENCY:
Letter of Dismissal from Employer
Proof of Unemployment Claim
Proof of Medical Bills
Proof of Loss of Other Income
Budget Showing Insufficient Funds
Other
PROOF OF ABILITY TO PAY IN THE FUTURE:
Notarized Letter from Friend/Family Member Stating that will Assist and Verification that they are Able to Provide Financial Assistance
Letter from Employer
Award Notification Letter
Financial Analysis
Pay Stubs
Employment History
Other
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INTAKE - II
PEPCO/GAS PROGRAM
CLIENT INFORMATION
Name of Applicant:
Social Security #:
Sex:
Male
Female
Date of Birth
Source(s) of Income - (Check all that apply): Documentation Required
AFDC/TANF
Child Support
Employment
Retirement
SSI
Disability
Social Security
Other
Race
African-American
Hispanic
White Non-Hispanic
Asian American
Other
Marital Status
Married
Divorced
Seperated
Single
Widowed
Head of Household
Yes
No
Family Size
# of Adults
# of Children
# of Males
# of Females
Total
Education (Highest grade completed)
No HS Diploma/GED
HS Diploma
GED
College Degree
Graduate Degree
Certificate/Awards
Household Type
S-Single
SP-Single Parent
TP-Two Parents
GP-Grandparent
Household Members
Click "add more" to add as many household members as needed
SSN (Last 4 Digits)
DOB (MM/DD/YYYY)
Age
Sex
Relationship to Applicant
Add More Household Members
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PEPCO/GAS PROGRAM
FINANCIAL NEED
Name of Applicant:
Utility Information
Name on Account:
Account Number:
Service Address:
Contact Person:
Financial Needs of Applicant
PEPCO
GAS
Monthly amount of utilities
Monthly amount of utilities
Total amount deliquent on (utility) bill
Total amount deliquent on (utility) bill
Total contribution by applicant
Total contribution by applicant
Balance Needed
Balance Needed
Amount Requested
Amount Requested
How will applicant make future payments? (Use the additional text space if needed)
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 PEPCO/Washington Gas representative to gather any necessary information from agencies of individuals involved in my case to qualify me for funds.
Client Signature
Date
MM
/
DD
/
YYYY
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Upload Your Documents Here In Order To Submit Your Application
Please upload in doc., docx, jpeg, png, or pdf format.
Photo ID
Delete all uploads
Choose files or drag here
Social Security Card(s) - (For everyone 18 and under)
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Birth Certificate(s) - (For everyone 17 and under)
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Choose files or drag here
Proof of Income
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Current Bill
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Proof of Residence - (Lease or Mortgage Statement)
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Letter of Hardship - (Stating circumstance for needing assistance)
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Verification
SUBMIT FORM
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