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programs guidelines, and based on the date the (City of Seattle)

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Mail Application: 700 5
th
Ave Sts 2832
Seattle, WA 98124
To Fax Application: 206-287-5356
To Email SCL_InfoELIA@Seattle.Gov
ELIA Phone number 206-684-3688
City of Seattle
Assistance Programs Application
the ELIA Program
This universal application may be used to apply for &/or enroll into the following City of Seattle Programs. For emergency assistance the Emergency Low
Income Assistance Program (ELIA). The Seattle Public Utilities Emergency Assistance Program (SPU-EAP) and the Utility Discount Program (UDP) and the $20
Car Tab Rebate Program. Please note the income guidelines for the Emergency Assistance Programs are at 80% State AMI and the UDP & $20 Car Tab
programs are at 70% State median income. Eligibility is based on meeting each individual program enrollment criteria, meeting annual income per each
program’s guidelines, and based on the date the application is completed and received by the city. Applications are processed in the order they are received.
☐ Government issued Identification for all persons 18 years and older. Please provide a
copy of one of the items below for each adult:
• State driver’s license
• State identification card
• Passport or Permanent Resident Card
☐ Please provide your Food Assistance SNAP benefits client ID or your social security
number below to provide verification of gross income to enroll in the UDP Program.
SNAP Benefits Client ID:
If you are not on SNAP, please provide income documentation for ALL persons 18 years old and older living in
your home. Please provide verification of GROSS income received in the previous
month:
• Paycheck stubs/Employer statement showing GROSS earnings
• DSHS award letters (TANF, GAU/GAX)
• Child support
• Social Security/SSI award letter/Survivor benefits
• Pensions/Annuity/IRA, Interest & Dividends
• Labor and Industry (L&I) statement
• Student financial aid and tuition statement
• Rental/investment property income (Provide a copy of lease/rental agreement.)
• Self Employed (Most recent full tax return & 3 months profit & loss statements)
• Other Income ________________
• Please have _____________complete the highlighted sections and sign the
enclosed "Request for Records" form and mail it with your application.
Primary Name on your Seattle
City Light bill:
Last
First
Middle
Physical Address:
Street
Apt#
City
Zip
Mailing Address:
Street
Apt#
City
Zip
Primary Phone:
E-Mail:
Seattle City Light (Account) #:
Seattle Public Utilities (Account) #:
Car License Plate Number:
Date Registration Paid: / /
Car License Plate Number (2
nd
vehicle):
Date Registration Paid: / /
REV 11-30-19
Please complete the front and back of this form
☐ ELIA - 206-684-3688
☐
SPU-EAP-206-684-5800
☐
UDP-206-684-0268
☐ PROJECT SHARE
☐ $20 Car Tab Rebate
check all that apply or call
if you have questions
OR Social Security #
Email is not considered secure.
By choosing to communicate with City Light by email,
you assume the risk of a confidentiality breach.
$
HOUSING INFORMATION
Household members include everyone living in the home, regardless of age, whether or not they pay rent, and their
relationship to applicant. Examples: roommates, relatives, tenants, children, friends, extended family members, etc.
Name (Last, First)
Date of
Birth
Sex
Relationship
to You
Gross
Monthly
Income
Income Source (employers
name, Social Security, TANF,
etc.)
M F
Myself
$ ___
M
$ ___
M F
$ ___
M F
$ ___
M F
$ ___
Total number in household: If more than 5, list other household members on a separate page.
Source of income or benefits (please check all that apply):
Wages Unemployment Child Support Adoption Support TANF/ABD
Pension/Annuity RCA VA Rental income HEN
Social Security/SSI Other:
HOUSING INFORMATION
Amount you pay for rent or mortgage: $ If rent is subsidized (check one):
Housing Status: Seattle Housing Authority WSHFC
King County Housing Authority Other:
Housing Type: Single Family Home 2, 3 or 4 Units Apt. Building Condo Mobile Home
How do you heat your home? Electric Gas Oil Wood Other:
Cable TV customers may qualify for a low-income discount. If you subscribe to Cable TV, which company?
Comcast Wave Other:
OPTIONAL INFORMATION
How do you identify yourself: Multi Racial Native American, Alaska Native Asian American/Asian
Black, African American, African Hispanic, Latino Hawaiian Native, Pacific Islander White, Caucasian
Other?
What is your primary language?
How did you hear about our services? Radio Television Newspaper Newsletter
Utility Bill insert Website Family or friends Other: _____________ ONLINE APPLICATION
As a participant of the Utility Discount Program, you may be eligible for additional governmental benefits. If you do NOT wish
to receive notices for additional City of Seattle and/or King County benefit programs, please check this box.
☐
SIGNATURE
I am aware that my information is subject to review and verification and that other documentation may be required.
I grant permission
to request information from the Seattle Housing Authority, Sec 8, HUD, King County Housing Authority, other
government agencies, or
their delegated agents; this may result in receipt or denial of City benefits. Submitting this application does not guarantee
eligibility or
enrollment in any programs.
I certify that the information I provided is accurate and complete and that I may be subject to criminal prosecution if I have knowingly
given false or misleading information. I agree to provide updated proof of eligibility at any time, if requested. I understand that if I am
found to be in violation of program rules, and receive assistance and have not truly disclosed all information, I will be removed from the
program(s) and the City may recover the actual cost(s) for the periods I was not eligible.
I will notify the City of Seattle if my
income
or living situation changes.
Primary Name on SCL Bill
Sig
nature:
Date:
Personal information entered on this form is subject to Washington Public Records Act, and may be subject to disclosure to a third-party requester. At the City of Seattle, we are
c
ommitted to protecting your privacy and will ensure that any disclosures are done according to law. To learn more about how this information is managed please see our Privacy
Statement. ( http://www.seattle.gov/tech/initiatives/privacy )
F
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Completed 25 June 2021

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