Fillable Utility Assistance Application

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Utility Assistance Application

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Utility Assistance Application
INSTRUCTIONS
1. Has anyone in your Household received utility or rent/mortgage assistance in the last 12 months?
a. If no, then continue to step 2
b. If yes, please know that you must wait at least 90 days before requesting additional
assistance. If it has been more than 90 days since you have been assisted, you may reapply
but assistance is not guaranteed.
Please continue to step 2.
2. Provide legible copies of all required documentation (see next page).
Your application must be submitted with all required documents. If you are missing any documents or
signatures, a case manager will contact you and allow you 3 business days to complete your
application. If the case manager is not able to successfully complete your application, the case may be
denied.
3. Fill out all forms attached. The applicant must sign ALL forms but do not date.
Please DO NOT date any of the forms
4. Drop off, email, fax, or mail the completed application packet to:
A New Leaf- MesaCAN
635 E Broadway Road, Mesa, AZ 85204
Phone: 480-833-9200 Fax: 480-833-9292
Mesacanclient@turnanewleaf.org
Please be advised that it may take up to 10 business days to review
OFFICE USE ONLY
Applicant’s Name: _______________________________Date Received: _____________
Approved: __________ Denied: __________ MesaCAN Initials: _____________
DOCUMENTS REQUIRED FOR UTILITY ASSISTANCE
All documents must be submitted with application
to be considered for services
1. PICTURE I.D. FOR APPLICANT
2. PROOF OF CITIZENSHIP FOR APPLICANT, and/or eligible household member –
any of the following forms are acceptable: birth certificate, passport, C.I.B., military discharge paperwork or DD-2 form,
certificate of live birth, recent Social Security Income award letter, recent DES nutrition or cash assistance award letter
with name and date of birth. If born outside of the US, please provide proof of legal permanent resident status or US
citizenship. Social security cards are not proof of citizenship.
3. SOCIAL SECURITY CARDS FOR ALL HOUSEHOLD MEMBERS, or legal document stating the name and social
security number; social security award letter, DES print out, or income tax forms are acceptable.
4. PROOF OF INCOME FOR ALL HOUSEHOLD MEMBERS – for the last 30 days
this includes; paychecks, current benefit award letters, unemployment, child support, school financial aid, and any other
source of income from employment, self-employment or benefits.
Zero income statement is required for household members 18+ without income
Bank statements are not acceptable proof of income
5. UTILITY BILLS (Electric, gas, water)– Copy of the most recent utility bill, disconnection notice, deposit letter, or
M-POWER account receipt
Household Information Form
Do you or any household member meet any of the following criteria? Please select all that apply:
Utility services
disconnected
Elderly (60+)
Child age 6 and Under
Applicant Name: _______________________________________________ Phone Number: _________________________________
Address: _____________________________________________________ Email: _________________________________________
What is the primary language in your household? ______________________________________________________________
Living Arrangement: (Please Circle) House / Mobile / Apartment / Other Housing type: (Please Circle) Rents / Owns / subsidized / No pay / Homeless
Food Stamps (SNAP) Yes No Food Stamps (SNAP) Case Number ______________________ Date in County: ___________________
Cash Assistance (TANF) Yes No If yes, Monthly Benefit $ ________________________________ Court Order Child Support: Yes No
Are either you or a member of your family an A New Leaf employee? Yes No
If yes, name of employee: ________________________________________________________________________________
Utilities:
SRP Account number: __________________________________ Status: Shut Off Delinquency/Disconnect Notice Payment Current
City of Mesa Account number: ____________________________ Status: Shut Off Delinquency/Disconnect Notice Payment Current
SWG Account number: _________________________________ Status: Shut Off Delinquency/Disconnect Notice Payment Current
Other (please specify): __________________________________ Status: Shut Off Delinquency/Disconnect Notice Payment Current
Household Health Insurance Type (Please select one):
Type:
AHCCCS
KIDCARE
Medicare
VA
Employment Base
Insurance
Private
Tribal
NONE
Provider Name:
(please add first name of household member, if more than one insurance type)
Please list all Household Members – Start with applicant
Name
Date of Birth
Relationship
to Applicant
Social Security
Number
Gender
Race
Hispanic/Latino (Y/N)
Educ
ation level
Vet
eran (Y/N)
Marital status
Home bound (Y/N)
Disabled (Y/N)
Health insurance (Y/N)
Place
Of
Birth:
Applicant
M F
M F
M F
M F
M F
M F
Additional household member information can be continued on back
Income Information Notes: ___________________________________________________________________________________________
Please document crisis here: __________________________________________________________________________________________
__________________________________________________________________________________________________________________
The information provided above DOES NOT determine eligibility or financial assistance; this form is used solely to gather information
INCOME INFORMATION
Last 30 days
Income by HH
Member Name
Income Source
(Name and Phone #)
Frequency
(Monthly,
Bi-weekly,
Weekly,)
Date
Received
Gross Amount Received
(Before Deductions)
$
$
$
$
PAYMENT INFORMATION
PLEASE PRINT LEGIBLY
APPLICANT’S NAME (Last, First MI)
APPLICANTS SOCIAL SECURITY #
Account #
Voucher
#
Vendor
Code
Vendor Name
Billing Name
Servic
e
Code
Fund Source
Amount
Categorical
Eligibility
Yes/No
Need
Guarantee
Yes/No
$
$
$
$
$
VENDOR/PAYEE NAME (check to be issued to):
VENDOR/PAYEE MAILING ADDRESS (No., Street, Apt. #, City, State, ZIP):
Actual Mo.
Rent/Mortgage
EIN No.
Has the household received STCS services in the prior 12 months? Y/N If yes, what agency:
Approved Denied
APPLICANT’S STATEMENT OF TRUTH
Under penalty of perjury and acknowledged by my signature below, I swear or affirm that the statements made in this application regarding the persons in my home, and the income,
resources, property and all other items that pertain to my possible eligibility for services are true and correct to the best of my knowledge.
Bajo pena de perjurio y reconocido por mi firma abajo, juro o afirmo que las declaraciones hechas en esta solicitud con respecto a las personas en mi hogar y los ingresos, recursos,
propiedad y todos los demás elementos que pertenecen a mi posible elegibilidad para los servicios son verdaderas y correctas a mi leal saber y entender.
RELEASE OF INFORMATION
I authorize the Department of Economic Security and/or delegate agency to contact any source necessary to establish the accuracy of the information given by me. Further, I authorize any landlord, mortgage, or
utility company, to which payment of credit on my behalf may be made, to release information regarding my account including, but not limited to, billing information to State of Arizona and/or its contract designee. I
understand that Arizona Department of Economic Security may use information provided on this form for purposes of research, evaluation and analysis.
Autorizo al Departamento de Seguridad Económica y / o agencia delegada a contactar cualquier fuente necesaria para establecer la exactitud de la información proporcionada por mí. Además, autorizo a cualquier
arrendador, hipotecario o compañía de servicios públicos, a la que se pueda realizar el pago de crédito en mi nombre, a proporcionar información relacionada con mi cuenta, incluida, entre otras, la información de
facturación al estado de Arizona y / o la persona designada por el contrato. Entiendo que el Departamento de Seguridad Económica de Arizona puede utilizar la información proporcionada en este formulario para
fines de investigación, evaluación y análisis.
APPLICANT’S SIGNATURE
DATE
WORKER’S STATEMENT
I have interviewed the applicant and have explained his/her right to the appeals process. I have advised the applicant of any penalties for misrepresentation and/or Fraud. I have completed
my investigation of the applicant’s eligibility as required by program rules, guidelines, & regulations.
WORKER’S SIGNATURE
DATE
UTILITY INFORMATION RELEASE AUTHORIZATION FORM
Arizona Public Service UniSource Energy Services
Salt River Project Southwest Gas
Tucson Electric Power Other
By signing this form, I authorize the above named utility provider(s) (indicated by box checked) to
release my historical and future utility bills, account information (such as but not limited to name,
service address, account number, balance, payment history) and other information concerning or
related to energy consumption and costs to any and all of the agencies/persons listed on this form
(“Authorized Parties”). This release is granted in connection with my household’s request for and/or
receipt of assistance from the community agency listed below.
I understand and agree that the utility information released may be compiled and analyzed (both on an
individual household and combined basis) by one or more of the Authorized Parties. I further
understand and agree that the utility information released, as well as any statistical or other analysis
may be released by the Authorized Parties to a third party for reporting purposes related to assistance
received, and no information released shall be made public in such a manner that my dwelling or my
household occupants can be identified.
I further agree to release and hold harmless the above named utility provider(s) from: (i) any claims,
damages, liability or expenses resulting from the use or disclosure of information based on this
Authorization; (ii) the unauthorized use or disclosure of the information by any of the Authorized
Parties; and (iii) any actions taken by any of the Authorized Parties based on this Authorization.
Authorized Parties:
Community Agency:
Name of agency determining assistance _A New Leaf - MesaCAN_______________________________
Wildfire (Arizona Community Action Association) Arizona Department of Housing. Community Arizona Department of
Economic Security Development and Revitalization Division
Signature of Account Holder/Customer of Record: ______________________________________________________
Print Account Holder/Customer of Record: ____________________________________________________________
Signature of Joint Account Holder/Customer of Record: __________________________________________________
Print Joint Account Holder/Customer of Record: ________________________________________________________
Service Address: _________________________________________________________________________________
Account Number: ________________________________________________________________________________
Date: __________________________________________________________________________________________
AFFIDAVIT THAT DOCUMENT(S) IS/ARE TRUE
I,
, swear or affirm, under penalty of
Printed or typed name
perjury, that the document(s) presented by me to prove U.S. citizenship, U.S. national, or alien status are true.
Signature of applicant Date
DOCUMENT(S) PRESENTED (circle the document(s) presented; Original or Copy):
A Birth Certificate showing birth in U.S. or
Territories or possessions
Certificate of Birth issued by Dept of
State (FS-545, or DPS-1350)
Certificate of U.S. Citizenship (N-
560, N-561)
Amended U.S. Public Birth Record
U.S. Passport
Legal records showing applicant's
name and place of birth in the U.S.,
Territories or Possessions
Identification Card for use of
Resident Citizen (I-179)
Official notification of birth
registration from a U.S. State’s
Dept. of vital Statistics
U.S. Citizen Identification Card
I-197
Verification from Vital Records Office
sent directly to agency
Certificates of Live Birth signed by
a hospital official AND parent
Affidavit Attesting Citizenship
completed by a U.S. Citizen that is
not a hh member
U.S. Consular Officer's Statement
Current SSI or SSD Award letter
Verification from the Social
Security Administration, e.g. award
letter
Medicare Card
A current decision letter or system printout
from ADES/FAA demonstrating eligibility for
Food Stamp or Cash Assistance Programs
AHCCCS Award Letter
Foster Care assistance verification
under title IV-8 of the Social
Security Act (for children only)
Verification of Adoption subsidies
(for children only)
Report of Birth Abroad (FS 240) issued by
the U.S. State Department
Medical records
Certificate of Naturalization
(N-550, N-570)
Statement signed by the physician
or midwife who was in attendance
at the time of birth
Verification from USCIS
Alien Registration Receipt Card (I-151)
Religious record
Early School records showing
child’s date and place of birth
State census records
U.S. Census record
Proof of employment as U.S. Civil
Servant prior to 6/1/1976
DHS Verification Information
System (VIS) response validating
U.S. Citizenship
American Indian Census Record
Marriage certificate showing marriage
to a male U.S. citizen before 9/22/1922
Adoption finalization papers
Tribal census records for Navajo
or Seneca tribes
Resident Alien Card (I-551)
Military Papers
Life, health or other insurance
records
The roll of Alaska Natives from the
Bureau of Indian Affairs
A Tribal enrollment card or Certificate of
Indian Blood
Northern Mariana ID (I-873)
I-94 form
I-194 Card
American Indian Card (I-872 with
classification code KIC)
Equal Opportunity Employer/Program •Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA),
Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975, the Department prohibits discrimination in admissions, programs, services,
activities, or employment based on race, color, religion, sex, national origin, age, and disability. The Department must make a reasonable accommodation to allow a
person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters
for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any her reasonable action that
allows you to take part in and understand a program or activity, including making reasonable changes to activity. If you believe that you will not be able to understand
or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in
alternative format or for further formation about this policy, contact 602-542-3882; TTY/TDD Services: 7-1-1.
CLIENT RIGHTS
A New Leaf shall ensure that a client who does not speak English or who has a physical or other disability is
assisted in becoming aware of client rights
Each client must be afforded the following basic rights:
1. To be treated with dignity, respect, and consideration.
2. To have one’s needs met in a professional and ethical manner
3. Not to be discriminated against based on race, color, national origin, religion, gender, sexual orientation, age, disability, or
marital status.
4. To receive service that:
a. Supports and respects the client’s individuality, culture, choices, strengths, and financial goals.
b. Supports the client’s personal liberty.
5. Not to be prevented or impeded from exercising the client’s civil rights unless the client has been adjudicated incompetent or a
court of competent jurisdiction has found that the client is unable to exercise a specific right or category of rights.
6. To submit grievances to A New Leaf, MesaCAN staff members and complaints to outside entities and other individuals without
constraint or retaliation:
a. To have grievances considered by A New Leaf, MesaCAN (Here-in thereafter referred to as Agency) in a fair, timely, and
impartial manner.
b. To dispute the amount of assistance for which their circumstances qualify as Department of Economic Security and other
funding allows.
7. To seek, speak to, and be assisted by legal counsel of the client’s choice, at the client’s expense.
8. To receive assistance from a family member, designated representative, or other individual in understanding, protecting, or
exercising the client’s rights.
a. To participate or, if applicable, to have the client’s parent, guardian, custodian or agent participate in financial decisions and
in the development and periodic review and revision of the client’s written financial plan.
b. To control the client’s own finances except as provided by A.R.S. § 36-507 (5).
9. To have the client’s information and records kept confidential from release except in the case of court order, emergencies, or as
otherwise required or permitted by law.
10. To privacy during financial counseling, including the right not to be photographed or recorded without general consent, except
for temporary video recordings used for security purposes that are maintained only on a temporary basis, unless a release has
been signed.
11. To review, upon written request, the client’s own financial record during the Agency’s hours of operation or at a time agreed
upon by the program director.
____________________________________________________________________________________________________________
Client Name / nombre de cliente Client Signature / firma de cliente Date/ fecha
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Utility Assistance Application

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Completed 5 April 2022

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