Service Request Form - Catholic Charities

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Service Request Form

Catholic Charities serves all people regardless of their religion, race or ethnicity. If you are in need of services or support, please fill out the form below. Once submitted one of our staff will reach out to you.

1Terms and Conditions

2Utility Termination

3Personal Info

4Income

5Financials

6Service Request Info

7Utility Info

8Funding

9Dollar Energy

10LIHEAP

11Oil Info

Phone

This field is for validation purposes and should be left unchanged.

Terms and Conditions

Consent(Required)

Catholic Charities serves all people regardless of their religion, race or ethnicity. If you are in need of services or support, please fill out the form below. Once submitted one of our staff will reach out to you.

Catholic Charities is currently only providing help on utilities that are likely to be terminated. In order for our assistance process to go smoothly and promptly, we require the following documentation uploaded:

- An active termination with the inability to pay
- The past thirty days of income for all members of your household (this would include SSI, SSD, Pension, Cash Assistance, SNAP Benefits, etc.)
- All utility bills (not just the one you are asking for help with) with proof of the most recent payment.
- Proof of expenses paid in the past 30 days:
               - Rent/mortgage payments/receipts
                - Utility bill payments
                - Car payment/insurance fees
                - Credit card payments, loans
                - Phone, cable, internet, streaming services (Netflix, Hulu, etc.)
                - Rent-a-Center
                - Doordash, etc.
                - Uber, etc.
                - Habits (nicotine, alcohol)
                - Online shopping (Amazon, etc.)
                - Skill machines, online gambling, lottery tickets
                - Medical Marijuana expenses
- If you are asking for oil assistance, you will need to provide your company name and account number. You must have applied for LIHEAP/CRISIS first before Catholic Charities can assist.

I have read about the above required documents for assistance.

Have you applied with LIHEAP/CRISIS(Required)

If you need assistance with an oil bill, have you applied with LIHEAP/CRISIS first?

Yes

No

You must apply for LIHEAP/CRISIS first before we can assist you with your oil bill.

LIHEAP (Low-Income Home Energy Assistance Program) and CRISIS are federally funded programs designed to help eligible households with their energy bills. These programs must be used as the first step in seeking energy assistance.

Utility Termination

Do you have a utility termination?(Required)

You are ineligible. Once you have received a utility termination notice come back and complete the form.

Contact Info

Full Name(Required)

First Last

Email(Required)

Phone(Required)

Home Info

Full Address(Required)

Street Address City State ZIP Code

County(Required)

Household Income(Required)

Has your household had income in the past 30 days?

Income

Name(Required)

I state that no member of my household has received any source of income during the past 30 days.

First Last

Without Income(Required)

Our household has been without income since

MM slash DD slash YYYY

Date expected to recieve income(Required)

I hope and expect to receive some income on or about

MM slash DD slash YYYY

From(Required)

What do you expect you will have income coming from?

During the above period, how did your household meet their needs for:

Food(Required)

Shelter(Required)

Living Expenses(Required)

Other

Signature(Required)

SIGN YOUR NAME BELOW I understand that I can be denied services from Catholic Charities of the Diocese of Altoona-Johnstown for making false statements and do reaffirm that all claims here are complete and truthful to the best of my knowledge. By signing below, I understand and agree that this electronic signature has the same legal force and effect as a manual signature.

Utility Company Name:(Required)

Account Number(Required)

Financials

Gross Monthly Income(Required)

including income of all persons in the home

Number of persons in the home(Required)

USE NUMBERS ONLY, After entering a number then fields will display for you to enter names and birth dates.

Household Persons(Required)

Based on the number of persons in your home we will need names and birth dates for all. The number you enter above will show an amount of fields to complete.

First Name

Last Name

Birth Date

Proof of Income(Required)

Please attach any financial documents to prove income (FOR THE LAST 30 DAYS). SNAP ( welfare documents), SSI Income, Wages income, Retirement Benefits . if you are ZERO income you must provide paperwork from the welfare office supporting that.

YOU CAN UPLOAD MULTIPLE FILES. DRAG AND DROP MULTIPLE FILES OR CLICK (SELECT FILES) AND PICK MULTIPLE. ONCE ADDED YOU CAN ALSO REMOVE THEM EASILY.

Drop files here or

Max. file size: 1 GB.

Proof of Expenses(Required)

PROOF OF PAID EXPENSES (LAST 30 DAYS)
Please attach any financial documents to prove your expenses (FOR THE LAST 30 DAYS). YOU CAN UPLOAD MULTIPLE FILES. DRAG AND DROP MULTIPLE FILES OR CLICK (SELECT FILES) AND PICK MULTIPLE. ONCE ADDED YOU CAN ALSO REMOVE THEM EASILY.

Drop files here or

Max. file size: 1 GB.

Service Request Info

I Received Past Help(Required)

Have you received help from Catholic Charities before?

YES

NO

Catholic charities help(Required)

Briefly list when you received help and for what.

I received Other Agencies Help(Required)

Are you working with any other agencies at this time?

YES

NO

Agencies Help(Required)

Briefly list what agencies helped and how much .

Utility Info

Name of utility(Required)

Utility account number(Required)

Utility named account(Required)

Is the utility in a personal name or in your landlords name? If in the landlord name then you are REQUIRED TO PROVIDE US A LEASE.

Personal Name

Landlord Name

Personal Name on utility(Required)

Landlord name on utility(Required)

Landlord Lease(Required)

YOU MUST SUPPLY THE LEASE. Upload /attach it here.

YOU CAN UPLOAD MULTIPLE FILES. DRAG AND DROP MULTIPLE FILES OR CLICK (SELECT FILES) AND PICK MULTIPLE. ONCE ADDED YOU CAN ALSO REMOVE THEM EASILY.

Drop files here or

Max. file size: 1 GB.

Utility Billing

Do you have a termination(Required)

YES

NO

Terminination Amount(Required)

Termination Date(Required)

Termination Document(Required)

Please upload your termination document. Take a picture or scan it in and attache it here.

YOU CAN UPLOAD MULTIPLE FILES. DRAG AND DROP MULTIPLE FILES OR CLICK (SELECT FILES) AND PICK MULTIPLE. ONCE ADDED YOU CAN ALSO REMOVE THEM EASILY.

Drop files here or

Max. file size: 1 GB.

Is the service on or off(Required)

ON

OFF

Date of last payment(Required)

Amount of last payment(Required)

Reason you cannot pay the bill(Required)

Can you contribute to the bill?(Required)

YES

NO

Contribute Amount(Required)

How much can you contribute this month?

Funding

Past Funding Received(Required)

Have you received funding in the past 12 to 24 months ?

YES

NO

Funding from who?(Required)

Funding for what?(Required)

Funding Amount(Required)

How much funding did you receive?

I applied for Dollar Energy(Required)

(If request is for assistance with a People Natural Gas or Penelec bill)

YES

NO

Dollar Energy Utility / Received

Utility Provider(Required)

What utility provider did you apply for dollar energy funder with?

People Natural Gas

Penelec

Other

Other Utility Provider(Required)

Please list your provider.

I Received Dollar Energy funding(Required)

YES

NO

Amount Received(Required)

Enter the amount of Dollar Energy funding you received

LIHEAP

The Low Income Home Energy Assistance Program (LIHEAP) helps families living on low incomes pay their heating bills in the form of a cash grant.

I applied for LIHEAP-Crisis(Required)

YES

NO

LIHEAP Utilities Applied for(Required)

What LIHEAP utilities did you apply for?

gas/electric

heating fuel (oil, coal, propane,wood)

I received LIHEAP-Crisis(Required)

YES

NO

Utility you received for LIHEAP?(Required)

List all the utilities you received money from LIHEAP for.

LIHEAP-Crisis amount received(Required)

List the amount you received from LIHEAP-Crisis

Oil Fuel Source

Oil Fuel Source(Required)

Do you have oil as a fuel source?

YES

NO

Oil Utility

Have you purchased oil yourself this season?(Required)

YES

NO

Oil company(Required)

Oil company account info(Required)

Provide your full address AND account number for your oil company. If you do not have your account number then just provide your full address.

I applied for oil LIHEAP-Crisis(Required)

YES

NO

What oil utility did you apply for?(Required)

List all the utilities you applied for LIHEAP.

I received oil LIHEAP-Crisis(Required)

YES

NO

Oil Utility you received for LIHEAP?(Required)

List all the oil utilities you received money from LIHEAP for.

LIHEAP oil amount received(Required)

Reason you cannot pay for oil delivery(Required)

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