Energy Assistance Application v2.0

Teco Energy Bill Assistance Application

Catholic Charities, Diocese of St. Petersburg, Fl
Financial Assistance:
Time

:HourMinutesAM/PM Option
Date for dow

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

A limited number of applications are accepted each Wednesday

from 8AM – 5PM.

Please book mark this site and check back.
Please let us know how you found this application.
How did you discover this service?
OPTIONAL
IMPORTANT -- DO NOT SUBMIT DUPLICATE APPLICATIONS!

A duplicate will eliminate the earlier submission and you will lose your place in queue. If you are unsure if you submitted an application check your email for a submission acknowledgement from the sender name includes "Jotform" or "Catholic Charities". That email is proof of your submission. If you don't find it check your trash, junk, and spam folders. If you need help or have questions about an earlier application, contact us here: Contact Case Managers or phone: (813) 631-4370, extension 2215
We make no assurance that submitting an application will result in approval for assistance. Funds are available on a first-come first-served basis, and funds may be exhausted at any time and without notice. Furthermore, we must comply with funder regulations regarding disbursing assistance.

We understand it can be frustrating to apply for services and ultimately be denied, but we must comply with mandated policies and procedures.

Please know that we will do whatever we reasonably can to assist you within funder guidelines.

Note that due to the high quantity of applicants it may take as long as 2 - 3 weeks to process your application.
Do you understand and acknowledge that submitting an application does not assure funding will be provided to you?
Verify your email by entering it twice, each entry must match

Confirmation EmailEnter your email address in both fields. Each entry must match.
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

Electronic Signature Consent

You must agree to consent to use an electronic signature to apply using this application. If you prefer not to use an electronic signature, you will find paper options in the link below labeled Electronic Signature Consent.

Below, you will give your consent to electronically sign documents in this application. Even though many options are already marked to indicate your acceptance, you will have choices throughout to decline. Most consent items are required for program participation.
Use the following links to read and review these agreements. Your participation requires your acceptance:

ELECTRONIC SIGNATURE CONSENT

RIGHTS AND RESPONSIBILITIES AGREEMENT

CLIENT CONSENT OF SERVICE

HIPAA NOTICE OF PRIVACY PRACTICES

RELEASE OF INFORMATION

SELF CERTIFICATION OF RESIDENCY
Applicant/Client Full Name:

First NameLast Name
Accept or decline the terms in the aforementioned consents and agreements:
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
ROI end date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Household name
IMPORTANT!

You are completing an application for {financialAssistance}.If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

APPLICATION CANCELED

Because you have declined our electronic signature consent and or our other agreements, you cannot complete an electronic application.

You may click the Back button and change your response or click the Electronic Signature Consent link to read about how to get a paper form.

If you close your browser at any time before clicking SUBMIT on the last page, no data will be preserved and no application will be submitted.

Social Security Number
Required for all financial services
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Birth Date picker widge

MonthDayYear
Address (current or most recent if homeless)

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Your county of residence (if homeless, choose of last permanent residence):
Other County
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.
Note that your application requires your acceptance of our funder's Self Certification of Residency. You continuation and submission of this application indicates your acceptance and applies your electronic signature to this form: SELF CERTIFICATION OF RESIDENCY.
Mobile or Preferred Phone Number
Providing a number indicates consent to callFormat: (000) 000-0000.
Alternate Phone Number
Providing a number indicates consent to callFormat: (000) 000-0000.
Are you a veteran?

Please consider designating up to 2 emergency contacts.
Add all household members, other than yourself, including any other adults and children
# household members age 18-64
Enter 0 if none
# household members age 65 and over
OPTIONAL
# household members under age 18
OPTIONAL
Number household members
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

Current employment status
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

Do you currently receive any form of income from any source?
Enter the total monthly amounts from these sources:
Wages/salary
Alimony/spousal support
Child support
Disability insurance
General assistance
Pension
SSDI
Unemployment ins.
Workers compensation
VA compensation
Other income:
Total monthly amount from these sources
Annual income
Zero Income Applicants: Note that claiming ZERO INCOME will apply your acceptance and signature to this document:SELF CERTIFICATION OF ZERO INCOME.
Do you receive any TANF, SNAP, or WIC benefits?
Enter the total monthly amounts from these sources:
TANF
TANF Child Care
TANF Transportation
Other TANF
SNAP
WIC
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

Note: your signature will be applied to this document Duplication of Benefits Statement

Warning: Section 1001 of Title 18 of the U.S. Code makes it ia criminal offense to make willful false statements of misrepresentation to any Department or Agency of the United States as to any matter within its jurisdiction.
Have you, or any member of your household applied for funds or assistance for these same or similar needs elsewhere
Aplication status
Name of the organization you applied to:
Amount of funds you have received, paid on your behalf, or have been pledged:
Date you applied:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Details or comments about your application:

Energy bill assistance applicants: we need the following documents for our funders:
- A copy of the bill you are seeking assistance in your name.
- Photo ID for adults in the household.
- Birth certificates for all children in the household.
- Income statement (paystub, food stam letter, child support statement, social security statement, AFDC statement, etc.)
- Social Security cards for all household members.
- A statement of hardship (unemployment, medical bills, or a written statement explaining the cause of your current financial challenge and why help is needed).
A case manager will contact you if additional documentation is required.

If any of these are unavailable now you will have the opportunity to send them later.

Instructions will be included in an email you will receive after submitting your application.
Upload items indicated above that are applicable to your application. Add as many files as necessary by clicking the button, adding, and then repeat. Added files will display below the button:

Browse files-Add File-Repeat
Add as many documents as available. Click-Browse-Add-Repeat Cancelof
Optionally, take a selfie so we will recognize you when you visit us:
IMPORTANT!

You are completing an application for {financialAssistance}. If you do not have a past-due utility bill in your name from this provider, see alternate resources here and end your application.

IMPORTANT!

You are completing an application for {financialAssistance}.If you do not have a past-due Teco bill in your name, see alternate resources here and end your application.
1. Review your application:

Using the page navigation buttons review your application carefully and correct any errors.

You may optionally save a copy of the forms filled using the Preview Filled Forms button below but note that your application will not be received until submitted.

If you do not wish to apply close your browser and your application will be destroyed. This can not be un-done.

2. Complete the CAPTCHA and click Submit

If shown, click the CAPTCHA and click the Submit button and wait. Do not close your browser or navigate away until the submission is complete.

The submit button will not display until the CAPTCHA is complete. If you delay after clicking the CAPTCHA you may have to click it again to access the Submit button.
Please let us know how we are doing with this application! We are working hard to make it as easy as possible for you to apply and still conform to mandated guidelines.

Your opinion matters!
That's disappointing! If you have any suggestions on how we could improve, please let us know:
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Teco Energy Bill Assistance Application