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COVID-19 Assistance Program

  1. This form should only be completed if you are applying for the COVID-19 Assistance Program because you have lost your employment status directly related to the pandemic. If you are eligible for the standard Low Income program, please utilize the Low Income application.

  2. Customer number can be found on the upper right hand corner of the Utility bill.

  3. Account number can be found on the upper right hand corner of the Utility bill.

  4. Example: Employer closed business, laid off, temporary unemployment, etc...

  5. Example: 1. John Doe, SSN# 1234, DOB 1/15/1980, 40 yrs old

  6. Please Read and Select a response to the following statements

  7. IMPORTANT: For verification purposes, please attach all forms showing loss of employment for the household. This can be a letter from your employer, or proof that you applied for unemployment benefits after March 19, 2020.

  8. Please type First and Last Name

  9. Please type First and Last Name

  10. Leave This Blank:

  11. This field is not part of the form submission.