Utility Assistance – United Way Pine Belt

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This field is for validation purposes and should be left unchanged.

If yes, please explain(Required)

If other, please explain(Required)

How much is your rent or mortgage?(Required)

Please write out each bill that you have to pay monthly, including water, power, gas, internet, car note, insurance, child support.(Required)

County(Required)

Phone(Required)

If yes, where?(Required)

Please list all sources of income (including food stamps, alimony, child support, payroll stubs, etc)(Required)

Please upload all proof of income(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Please upload a copy of your bill needing assistance(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Name of utility company(Required)

Please upload a valid photo ID and social security card for everyone living in the home(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 5.

Please provide your social security number(Required)

Please upload two full months of bank statements and/or debit card or cashapp print out(Required)

Drop files here or

Max. file size: 10 MB, Max. files: 10.

Utility Assistance Application