utility information

release authorization

Utility Selection:

Important Notice:

With my signature below, I authorize the above named utility provider(s) (indicated by box checked) to release my historical and future utility bills, account information (such as but not limited to name, service address, account number, balance, payment history) and other information concerning or related to energy consumption and costs to any and all of the agencies/persons listed on this form ("Authorized Parties").

This release is granted in connection with my household's request for and/or receipt of assistance from the community agency listed below. I understand and agree that the utility information released may be compiled and analyzed (both on an individual household and combined basis) by one or more of the Authorized Parties.  I further understand and agree that the utility information released, as well as any statistical or other analysis, may be released by the Authorized Parties to a third party for reporting purposes related to assistance received, and no information released shall be made public in such a manner that my dwelling or my household occupants can be identified.

I further agree to release and hold harmless the above named utility provider(s) from: (i) any claims, damages, liability or expenses resulting from the use or disclosure of information based on this Authorization; (ii) the unauthorized use or disclosure of the information by any of the Authorized Parties; and (iii) any actions taken by any of the Authorized Parties based on this Authorization.

Utility Assistance Application
Agency determining assistance: 
Society of St. Vincent de Paul- Phoenix
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affidavit

Society of St. Vincent de Paul- Phoenix

As indicated by my signature below, I solemnly swear, under penalty of perjury, that the following statements regarding my eligibility for services and benefits are true and correct to the best of my knowledge. 

CONSENT AND NOTICE REGARDING ELECTRONIC COMMUNICATIONS: By signing below,  Application is electronically signed. You agree your electronic signature is the legal equivalent of your manual signature on this Application for assistance.

ADDITIONAL DOCUMENTS NEEDED:
 

  • Photo ID for applicant and ID for all household members.
     

  • Proof of income for all adults in the household for the past 30 days (gross income, before any deductions) or state in affidavit 0 income in the past 30 days.
     

  • Current utility bill ( must be in applicant’s name)
     

  • NOTE: if a Deposit is being requested, proof of U.S. citizenship also needs to be sent

IF CRISIS WAS COVID-19 RELATED, PLEASE ATTACH  DOCUMENTS CONFIRMING ANY OF THE FOLLOWING, SUCH AS:

  • Notice of job loss from Employer

  • Evidence of reduced work hours

  • Any hospitalization documents

  • Notice of a Quarantine requirement

  • Childcare or school unavailability

Additional Documents -two options for sending:
Option 1 - if possible, please use the green "File" buttons below to attach the required files directly to this Application.  All attachments will be automatically included with your Application after clicking the blue "SUBMIT" below.
File 1
File 2
File 3
File 4
Option 2 - if you are using a cell phone, please take a photo of each required document listed above & email to help@svdp.info Please indicate your full name if sending each photo separate from this Application. Next, click the "SUBMIT" button to email your completed Application.
Please click SUBMIT to send your completed Application to the Society of St. Vincent de Paul - Phoenix Council.

Thank you!

Was your crisis caused by the impact of the coronavirus (COVID-19) pandemic?