Utilities Form
Your personal information is kept private and confidential. We do not share client information unless specifically authorized to do so.
First Name
Last Name
Date of Birth
Phone
Email
Mailing Address
Mailing City
Mailing State
Mailing ZIP
Ethnicity
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
Two or more races
White
Other
Gender
Male
Female
Other
Please upload a picture of your ID
Accepted file types: .jpg, .png, .jpeg, .tif, .doc, .docx, .pdf
Please upload your utility bill
Accepted file types: .jpg, .png, .jpeg, .tif, .doc, .docx, .pdf
Which provider do you need assistance with?
Atmos Energy
Ambit Energy
TXU Energy
Other
Other:
Account Number
Consent
I hereby certify that all information provided by me is true and correct to the best of my knowledge. I also authorize the Elder Financial Safety Center at The Senior Source to contact my utility provider to obtain information regarding my account if necessary.
I understand that the Elder Financial Safety Center at The Senior Source provides utility assistance once a year, and if wanted, I can participate in other programs and services of the Center that can better my financial situation.
Consent for Service
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Contact Information