Housing Assistance Inquiry Form
(please note this is not an application)
How did you hear about us?
Please select...
PWD Initiative 01.2021
City Council
Elected Official
Coordinated Intake
Impact Services
Website
Workshop
Social Media
Newspaper
Radio
Poster/Flyer
Word of Mouth
SSVF-Internal
BAC-Internal
PW-Internal
WHSP-Internal
OSH-Internal
MS-Internal
UGP-Internal
Churches
Intake Site
Senior Center
CASS Oil
LIHEAP
HUD/VASH
Prior Client
Vet Haven
Station House
VA
Vet Line
Bus Ad (Advertisement)
Other
Client Information
Salutation
Please select...
Mr.
Ms.
Mrs.
First Name
Last Name
Birthdate
Social Security Number
Marital Status
Please select...
Single
Married
Divorced
Widowed
Unmarried Partner
Preferred Phone
Please select...
Home Phone
Cell Phone
Sex
Please select...
Male
Female
Transgendered
Race
Please select...
African-American
American Indian or Alaskan Native
American Indian or Alaskan Native and Black or African-American
American Indian or Alaskan Native and White
Asian
Asian and White
Black or African-American and White
Hispanic
Native Hawaiian or Other Pacific Islander
Multiple Ethnicities
Prefer Not to Answer
White
Ethnicity
Please select...
Hispanic
Non-Hispanic
Prefer not to answer
Home Phone
Cell Phone
Email Address
Are you interested in applying for other Federal/State benefits?
Yes
No
Address
Street
Ex. 1234 South Front Street
Apartment/Unit Number
Zip Code
Only Philadelphia county residents are eligible for UESF’s utility and rental assistance. UESF can assist PA residents that have PECO service with applying for the PECO (CAP) program.
Housing Status
Type of Housing
Please select...
Street/Park
Car
Abandoned House
Hospital
Prison/Halfway House
Shelter
Friends/Family
Subsidized Housing
Transitional Housing
Rental by client-No Subsidy
Homeowner
If living in a shelter, which one?
Are you behind on your rent?
Yes
No
N/A
If behind on your rent, how much?
Do you have a notice to quit?
Yes
No
N/A
Do you have a court ordered eviction?
Yes
No
N/A
Are you a homeowner?
Yes
No
N/A
Are you behind on your mortgage?
Yes
No
N/A
If behind on your Mortgage, how much?
Do you have an Act 91 notice?
Yes
No
N/A
Do you have a Foreclosure Notice?
Yes
No
N/A
Household Members
Select the Number Of People In Your Household (you are considered Household Member 1, select one if only you)
Please select...
1
2
3
4
5
6
7
8
9
10
Household Member 1
First Name
Last Name
Date of Birth
Household Member 2
First Name
Last Name
Date of Birth
Household Member 3
First Name
Last Name
Date of Birth
Household Member 4
First Name
Last Name
Date of Birth
Household Member 5
First Name
Last Name
Date of Birth
Household Member 6
First Name
Last Name
Date of Birth
Household Member 7
First Name
Last Name
Date of Birth
Household Member 8
First Name
Last Name
Date of Birth
Household Member 9
First Name
Last Name
Date of Birth
Household Member 10
First Name
Last Name
Date of Birth
Income Information
Monthly Gross Income
$
Annual Gross Income
$
EARN Center/PA Career Link Information
Are you an active EARN center/PA CareerLink participant?
Please select...
Yes
No
Which EARN Center/PA CareerLink Are You Participating At?
Please select...
PA CareerLink- North
PA CareerLink- Northwest
PA CareerLink- Suburban Station
PA CareerLink- West
Additional Information
Did you serve in the US Military?
Yes
No
Page 3
Utility Arrearages
Do you have a PECO account?
Yes
No
For my PECO Bill, I am/have...
Shut-Off Notice Received
Terminated
1 billing cycle behind and over $25
Bill is Current
Electric Account Number
Total PECO Amount Owed
Do you have a PGW account?
Yes
No
For my PGW bill, I am/have...
Shut-Off Notice
Terminated
1 billing cycle behind and over $30
Bill is Current
Gas Account Number
Total PGW Amount Owed
Do you have a WRB account?
Yes
No
For my Water bill, I am/have...
Shut-Off Notice Received
Termintated
2 Billing Cycles Behind, Over $75 Dollars
Bill is Current
Water Account Number
Total Water Amount Owed
Are you enrolled in any of the following? check all that apply
PECO CAP
PGW CRP
Water TAP
None
N/A
Water Conservation Program
Are there any leaks in the home?
Yes
No
I don't know, please call.
Contact Information