Disaster Relief Utility Assistance

Disaster Relief Utility Assistance Application

* Indicates required field

Name *

First

Last

Physical Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address if different from Physical *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Household information:

Number of Adults: *

Number of Children: *

Total Monthly Income: $ *

Other Source of income *

Utility Bill Assistance Request:

Utility Company Name: *

Account number: *

ID Number *

Total Amount due: $ *

Amount requesting: $ *

Due date: *

Have you received assistance from our Church before? *

Yes No

Reason for Assistance: Please briefly describe current financial hardship: *

Required Documents:
Copy of recent bill, proof of income if available, Photo ID

Agreement and signature:
I certify that the information provided is true and accurate. I understand that completing this application does not guarantee assistance, and that the church is not able to apply more than $250.00 dollars towards a utility bill.

By checking this box you agree to the terms above. *

Agree

Date: *

Submit Application

You can also download a copy of the application and mail or drop off at the Church.

Disaster Relief Utility Assistance Application
File Size:	101 kb
File Type:	pdf

Download File

Shoal Creek Baptist Church
1867 E US Hwy 19E
Burnsville, NC 28714

Sunday School/Bible Study: 9:45 am
Sunday Worship: 11:00 am
Wednesday Evening Dinner: 6:00 pm
Wednesday Evening Service: 6:30 pm
*(Adult Small Groups and Groups for Kids of all ages)
*Bible Studies: Click here Calendar
*Small Groups: Click here for Calendar
*Youth and Children's Activities:

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