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COVID-19 FINANCIAL HARDSHIP UTILITY ASSISTANCE APPLICATION

  1. COVID-19 FINANCIAL HARDSHIP UTILITY ASSISTANCE APPLICATION

    City of Gadsden Community Development COVID-19 utility assistance program application. You can fill out this form online or pick up a form at the City of Gadsden - City Hall 90 Broad Street, Gadsden, AL 35901. If you have questions about this form or program call Community Development Planner Renee Baker (256) 549-4532.

  2. Applicant

  3. Head of Household

  4. Address & Contact Information

  5. APPLICANT AND FAMILY MEMBER INFORMATION

    (List applicant information on line 1 below and list information on EACH person in the household on lines 2-10)

  6. Enter the total number of persons in the household that are of Hispanic origin

  7. COVD-19 Information

  8. Check All That Apply

    By checking one of the statements below – you may be required to provide proof to document the statement.

  9. Gross Monthly Household Income

    Income (income BEFORE any deductions such as taxes, insurance, etc.) List for each person as listed above and include any alimony, child support, COVID-19 pay, Unemployment, Worker’s Compensation, Social Security, Disability, VA benefits, TANF/WIC, pension, retirement, etc.)

  10. EMPLOYMENT

  11. My job title at my employer prior to COVID-19 restrictions were put into place was:

  12. 1. Employment

    My employer has guaranteed my return to employment once the COVID-19 restrictions are fully lifted and I AM receiving unemployment compensation.

  13. 2. Employment

    My employer has contacted me to return to work and has guaranteed return to my previous position and scheduled hours.

  14. 3. Employment .

    My employer has not guaranteed my return to employment and I am NOT receiving unemployment compensation

  15. 4. Employment

    I returned to work

  16. UTILITIES

    Check All That Apply

  17. 1. I am experiencing financial hardship and am unable to pay for basic utilities for my current housing.

  18. 2. I can pay for basic utilities for my current housing.

  19. Account Information

  20. Account Information

  21. Account Information

  22. Account Information

  23. Need

  24. (Describe the need for assistance and how the household has been affected by the COVID-19 pandemic

  25. Authority for Release of Information

    In order to finalize this application, you must fill out an Authority for Release of Information Form at the Community Development Office. This cannot be completed online. After submission of this form you will be contacted by the Community Development office at the City of Gadsden. If you are not contacted you can follow up with Community Development at (256) 549-4532.

  26. Leave This Blank:

  27. This field is not part of the form submission.