Utility Assistance Application

General Information

Agency Name*

Email*

Phone*

Program Name*

Statistical/Background Information

Describe the program for which you are applying. Please include program duration in your response, as well as the length of time your organization has been providing this service.

If your agency targets specific client populations, please indicate below

If you received funds last year, please give statistical information. (i.e. outcomes)

How many unduplicated families did you serve with Utility Assistance last year?

How many unduplicated people did you serve with Utility Assistance last year?

How many utility assistance bills did the agency pay last year?

What is the maximum amount of assistance per household?

Current EFSP Phase

These funds apply to assistance for electric, gas, propane, firewood, and water; no telephone. (Over 50% of funding should come from sources other EFSP.)

State your need for this program, under normal circumstances, including supporting statistics. Please explain how the current EFSP Phase funds will be used to supplement your current services.

How will services continue for this program, should you not receive EFSP funds?

Please list the primary geographic areas of your clients for which EFSP funds, if awarded, will be used.

EFSP funds do not pay salaries; explain staffing for the services for which you are requesting funds.

Describe your collaboration and coordination with area service providers and county agencies.

What other agencies, if any, provide similar assistance to residents in your service area? How do you determine if your clients have received similar services from other agencies?

Briefly describe your current procedures for screening and intake, including determination of client's eligibility.

Will the current EFSP Phase award assist you in securing or leveraging funds from other sources?

What is the EFSP through the current Phase request as a percentage of the total Utility Assistance budget?

What is the anticipated budget for the Utility Assistance Program?

What is the estimated number of bills to be paid with the current EFSP Phase funds for this year?

What is the estimated number of families you anticipate serving with the current EFSP Phase funds this year?

What is the estimated number of people you anticipate serving with the current EFSP Phase funds this year?

What is the current EFSP Phase amount requested for Utility Assistance Funds?

What method does your agency use to allocate the current EFSP Phase funds to support clients that cannot pay?

Please provide a budget narrative pertaining to your organization's planned expenses for the current EFSP Phase funds, should funds be awarded. Please also provide detail regarding the sources in the Budget Summary Form in this application.