Self-Service Eligibility Assessment

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1. Is your utility bill past due, or are you in jeopardy of having your payment arrangement revoked? *
2. Have you made a payment in the last 90 days? *
3. Total Number of Individuals in the Home (Adults & Children)*
8 max
4. How much money (before taxes) did all the adults (persons age 18 or older) in your household receive in the last 30 days? Include money from work, Social Security, Child Support, etc.*
All SSI/SSDI money received by the children of the home must be counted as income as well.
Should be Empty:

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