Outreach Pre-Registration

Outreach Pre-Registration

(Please note this is not an application)

Thank you for your interest in UESF. By submitting this form, you consent to receive communications from us, including updates, promotions, and alerts. You may unsubscribe at any time. For more information, please review our Privacy Policy via https://uesfacts.org/about-uesf/private-policy/.

Inquiry Information

Please complete this form at least two days prior to attending an outreach event. Event dates are posted monthly at www.uesfacts.org

Location Attending

Date Attending

Are you interested in tax services?

First Name

Last Name

Birthdate

Gender

Marital Status

Primary Language

Race

Referred By

Ethnicity

Citizenship

Social Security Number (Numbers only)

Other - Country Name

Passport/ITIN Number

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

If over 18, Social Security Number

Household Member 3

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 4

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 5

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 6

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 7

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 8

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 9

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Household Member 10

First Name

Last Name

Date of Birth

If over 18, Social Security Number

Income Information

I hereby certify that I currently earn income, listed below, and can provide documentation demonstrating my current income, if asked. (For example: W-2, 1 month of Paystubs, TANF or SSI Statement, etc.)

Gross Monthly Income

$

Sources of income (select all that apply)

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

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.

· 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

The following documents are required before a utility grant can be approved. If you do not have digital documents available at this time please bring paper documents to the UESF outreach event you plan on attending. (Documents are required for all household members over the age of 18.)

Most recent Utility Bill or Termination (Credit Denial Letter) or Shut-Off Notice
Proof of Income (last 30 days)
Drivers license or State ID of primary applicant
Social Security Card of primary applicant

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

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

You must indicate that you are interested in applying for at least one utility in order to submit this form.

Please click “Previous Page” to select the utility(ies) you are interested in applying for, or exit the survey if you are not interested in applying for any utility(ies).

Contact Information