Client Utility Grant Inquiry Form

Attention: Do not complete this form unless you have the following documents readily available. You are required to upload some or all of the following documents before submitting an inquiry form to UESF. Acceptable forms of documentation include: PDFs, scanned documents, photos, or screenshots. File names cannot contain special characters. Inquiries missing documentation will not be processed.

-Proof of gross income from the past 30 days for all household members over 18 years of age.

-Copy of your state issued photo ID or passport (include copies for household members over 18

years of age).

-Copy of your social security card (include copies for household members over 18 years of age).

-COMPASS benefits statement for the entire household (if received).

-Copy of your most recent utility bill(s) or shut-off notice.

*Please note this is not an application.

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Internal Fields

Application Site

Application Completed By

Inquiry Information

First Name

Last Name

Birthdate

MM/DD/YYYY

Gender

Marital Status

Primary Language

Race

Referred By

Ethnicity

Citizenship

Social Security Number (Numbers only)

Other - Country Name

Passport/ITIN Number

What is your living situation?

Are you an ACTIVE Earn Center client?

YesNo

If yes, which site?

Address and Contact Information

Street

Zip Code (5 digit Zip Code only)

Preferred Phone Type

Work Phone Number

Household Phone Number

Mobile Phone Number

Email Address

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.

Household Members

Select the Number Of People In Your Household (you are considered Household Member 1, select one if only you)

Household Member 1

First Name

Last Name

Date of Birth

Household Member 2

First Name

Last Name

Date of Birth

Social Security Number

Household Member 3

First Name

Last Name

Date of Birth

Social Security Number

Household Member 4

First Name

Last Name

Date of Birth

Social Security Number

Household Member 5

First Name

Last Name

Date of Birth

Social Security Number

Household Member 6

First Name

Last Name

Date of Birth

Social Security Number

Household Member 7

First Name

Last Name

Date of Birth

Social Security Number

Household Member 8

First Name

Last Name

Date of Birth

Social Security Number

Household Member 9

First Name

Last Name

Date of Birth

Social Security Number

Household Member 10

First Name

Last Name

Date of Birth

Social Security Number

LIHEAP/Crisis

Did you apply for LIHEAP?

Date of LIHEAP Application?

LIHEAP $

Please add a $ in front of the amount.

Did you apply for Crisis?

Date of Crisis Application?

Crisis $

Please add a $ in front of the amount.

PECO Information

Applying for PECO?

Address on PECO bill the same as home address?

If No- Please Provide Documentation

If address on PECO bill is not the same as home address, or if name on PECO bill does not match client's name, please provide documentation.

PECO Account Number

PECO status

Total PECO Balance $

PECO Application needs Turn On?

PGW Information

Are you applying for PGW?

Address on PGW bill the same on home address?

If address on PGW bill is not the same as home address, or if applicant name is not the same as name on PGW bill, please provide documentation.

PGW Account Number

PGW Status

Total PGW Balance $

PGW Application needs Turn On?

PWD Information

Are you applying for PWD?

PWD-Applicants name on Water Bill?

If NO- client is not eligible for servcies

PWD-Address on Water bill same as home address?

If NO- Client is not eligible for services.

If address on Water bill is not the same as home address, or if name on Water bill does not match client's name, client is not eligible for services.

PWD Account Number

PWD Status

Total PWD Balance $

PWD Application needs Turn On?

Required Documents

I agree to the following:

I, the applicant, do hereby certify that I have not, nor has any member of my household

applied for a Utility grant through UESF’s Utility Grant Program within the past two years or have not recieved a MEAF grant within the past 12 months.

· I, the applicant, give UESF authorization to request information from and/or speak with any representatives from my utility companies (if receiving utility assistance), with my landlord, property management company, or mortgage lender (if receiving housing assistance), and/or with any of my social service providers or medical professionals if input from these parties is necessary for the processing of my application for assistance.

· I understand that the information supplied in this application will be reviewed by individuals involved in the approval of financial assistance at UESF.

· I understand that UESF can release information on my application for the purpose of reporting to key funders and stakeholders who support the provision of utility and housing assistance to low income families.

· By pressing submit, I acknowledge and permit representatives of UESF to verify all information. Any intentional misrepresentation of information contained in this application will result in forfeiting my grant application(s) now and in the future.

Submitting this inquiry does not guarantee approval for the UESF utility grant.

Thank You - UESF

Please upload all required documents outlined on page one and below before submitting.

Acceptable forms of documentation include: PDFs, scanned documents, photos, or screenshots. File names cannot contain special characters. Inquiries missing documentation will not be processed.

-Proof of gross income from the past 30 days for all household members over 18 years of age.

-Copy of your state issued photo ID or passport (include copies for household members over 18 years of age).

-Copy of your social security card (include copies for household members over 18 years of age).

-COMPASS benefits statement for the entire household (if received).

-Copy of your most recent utility bill(s) or shut-off notice.

Personal Identification

Applicant's Driver's License or State ID

Applicant's Social Security Card

Income

Proof of Gross Household Income for Entire Past 30 Days

Utilities

Utility Bill OR Shut-off Notice (PECO, PGW, PWD)

COMPASS

Do you receive COMPASS benefits?

YesNo

Full COMPASS Report (mandatory if receiving benefits)

Additional Household Members

Do you want to add additional household members?

YesNo

Name of Household Member

Household Member's ID

Household Member's Social Security Card

Proof of Gross Household Income for Entire Past 30 Days

TANF-Public Assistance	Earned Income	Pension/Retirement Income
Social Security	SSI	Other
No Income	Self-Employment/Business Income	Alimony and Child Support Income
VA Disability	Income from Foster Care	Unemployment Compensation
Worker's Compensation	SSDI