EnergyUnited

Please Note:

APPLICANTS MAY SUBMIT ONLY ONE APPLICATION EVERY SIX MONTHS.

If you complete this form prior to six months from your last application, unfortunately, it will not be considered for a grant until the six month date.

Documentation Needed

Before proceeding with this application, please be sure to have the following documents ready to upload. You will not be able to complete the application without these documents.

1. Verification of your most recent monthly income (for all in the household) and all current
household bills.
2. A copy of pages one and two of your most recent Federal and State tax returns. W-2 forms,
pay stubs, or 1099’s will not be accepted in place of tax returns.
- Federal and State tax returns are required for each person in the household who files
3. Proof of Social Security income or a statement of disability from your physician.
4. If you or a household member has a medical situation not pertaining to disability, please
provide verification (doctor's statement, official medical records, etc.) of this medical
condition with this application.
5. If you are requesting assistance with items other than monthly bills, i.e. house repairs, car
repairs, etc., please submit at least two detailed estimates with your application. Estimates
must be from different vendors for the same item(s) or work with the same materials and
labor stated separately on each estimate. Applications with only one estimate will be
returned.

Application Due Dates

All applications are due by the 25th of the month to be considered the third Tuesday of the following month. Any applications that are received after the 25th will be considered two months later. If the 25th falls on a weekend or holiday, the application must be received by the last business day prior to the 25th.

Notable Information

The information obtained in this application is solely for the purpose of determining qualification for a grant from the EnergyUnited Foundation, Inc. and will be kept in strictest confidence. The person signing this application warrants that the information provided is true and complete. EnergyUnited Foundation, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. Any deliberate falsehoods detected will be strong grounds to deny the assistance application.

To receive assistance from the Foundation, you do not have to receive electric power from EnergyUnited, but you must reside within EnergyUnited’s electric service area.

Funding Criteria

The EnergyUnited Foundation, Inc. Board of Directors shall disburse funds donated by members of EnergyUnited on behalf of individuals and households who are suffering unusual and/or unexpected problems and are in grave need of assistance. Grants may be used to pay for items such as shelter, bills, emergencies, and other humane needs. Grants ARE NOT awarded for school tuition and fees, medical bills or business related expenses.

APPLICANTS MAY ONLY SUBMIT ONE APPLICATION EVERY SIX MONTHS.

Disbursements are limited to $5,000 within a 12 month period for individuals and $10,000 within a 12 month period for households.

To ensure confidentiality, decisions made by the EnergyUnited Foundation Board of Directors will NOT be discussed with anyone. Reasons for Board decisions will not be given to anyone, including the applicant, if the request is granted or denied.

Location

County of Residence:

Zip Code:

REQUIRED

The information provided in the application to EnergyUnited Foundation is true and complete. The Foundation is authorized to contact doctors, employer, any agency that provides assistance, and others to verify the information provided. I understand any deliberate falsehoods or efforts to mislead the Foundation will be strong grounds to deny the requested assistance. I also understand that the information contained in this application may be shared with other agencies or groups providing assistance.

I HAVE READ AND UNDERSTAND THE CRITERIA REQUIRED FOR THIS GRANT

Yes

Applicant Information

Name (First and Last)

Email Address

Is your physical address different than your mailing address? (we need a physical address if different than mailing address)

Yes

No

Street (Mailing Address)

City (Mailing Address)

State (Mailing Address)

Zip Code (Mailing Address)

Street (Physical Address)

City (Physical Address)

State (Physical Address)

Zip Code (Mailing Address)

Phone

Other Phone Number (if applicable)

Last 4 of SSN

Date of Birth (MM/DD/YYYY)

Marital Status

Employer Information

Are you currently employed?

YesNo

If not currently employed, are you receiving (check all that apply)

SSDSSIUnemployment IncomeOther

If other, please specify

Employer (Company Name)

Employer City

Employer State

Hours Worked Per Week

Hourly Rate of Pay

Former Employer (Company Name)

Last day worked:

Hourly Rate of Pay at Previous Job

Hours Worked Per Week at Previous Job

Persons Living in the Home

List all family members that live in the home below.
Please List: Name, Age, Date of Birth, Last 4 of SSN (if over age 18), Relationship to Applicant, and Employer / School

Family Member Info:

Salesforce Info

Program ID

Record Type ID

Other

If you have children, do you receive child support?

YesNo

How much child support do you receive per month?

Have you, or someone on your behalf, previously submitted an application?

YesNo

Are you currently under doctor's care or disabled?

Yes

No

If under a doctor's care or disabled, please attach a doctor's statement of condition with a diagnosis or proof of disability

Name of Doctor

Tax Returns

Did you file a tax return last year?

YesNo

How did you spend the money you received from your most recent tax return?

Please provide proof of any expenses over $500 from tax refund

Attach a copy of pages 1 & 2 of last year's Federal (Form 1040) and State (D-400) for yourself and everyone living in the home (click 'add another response' to add additional documents)

REQUIRED

The information provided in the application to EnergyUnited Foundation is true and complete. The Foundation is authorized to contact doctors, employer, any agency that provides assistance, and others to verify the information provided. I understand any deliberate falsehoods or efforts to mislead the Foundation will be strong grounds to deny the requested assistance. I also understand that the information contained in this application may be shared with other agencies or groups providing assistance.

I HAVE READ AND UNDERSTAND THE CRITERIA REQUIRED FOR THIS GRANT

Yes

Salary / Monthly Income	Medicare / Medicaid
Disability	Retirement
Child Support	Food Stamps
Work First	SSI
Housing Assistance	Unemployment
Other Pensions	Workers Compensation
Pell or Educational Grants	Other

Mortgage / Rent	Electricity
Telephone (landline)	Cell Phone
Water / Sewer	Cable TV / Internet / Streaming Services
Home Heating Oil or Gas	Groceries
Car Payment	Car Insurance
Homeowners or Renters Insurance	Medical Bills
Prescription Medicine	Credit Cards
Loans or Other Debts

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