Utility Application for Extension

EXTENSION APPLICATIONS MUST BE FILED BY 5PM ON THE LAST DAY OF THE MONTH.

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CUSTOMER INFORMATION:

NAME: *

SERVICE ADDRESS: *

CITY / STATE / ZIP CODE *

EMAIL ADDRESS: *

CUSTOMER PHONE NUMBER:

ACCOUNT INFORMATION:

UTILITY ACCOUNT NUMBER:

AMOUNT OWED: $

REQUESTED EXTENSION DATE: *

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edit-submitted-account-information-requested-extension-date-day

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Indicate the date you are requesting an extension to.

REQUESTS: *

This is the first time I have requested an extension.

I have applied previously.

Enter the date you previously asked for an extension. *

HOUSEHOLD INFORMATION:

OWNERSHIP INFORMATION: *

Home owner (or buying)

Renter

INDICATE YEARS AND MONTHS AT THIS LOCATION: *

LIST ALL HOUSEHOLD MEMBERS
Name	Age	Handicapped?
Name	Age	Handicapped? Yes No
Name	Age	Handicapped? Yes No
Name	Age	Handicapped? Yes No
Name	Age	Handicapped? Yes No
Name	Age	Handicapped? Yes No

SOURCE OF INCOME:
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received
Name	Source of Income	Amount received

List each household member who has received income in the last thirty (30) days.

ASSISTANCE:

These organizations can be contacted for help: Neighborhood Center 512-756-4334 LaCare 512-756-4422 (Wed. & Fri.) Salvation Army 512-756-2128

REASON ASSISTANCE IS NEEDED: *

HAVE YOU EXHAUSTED ALL OTHER SOURCES OF COMMUNITY HELP BEFORE MAKING THIS APPLICATION? *

Yes

WHO HAVE YOU CONTACTED:

CERTIFICATION: (La CERTIFICACION))

I certify that the information provided is true and correct to the best of my knowledge and belief. (Certifico que la información proporcionó es verdad y correcto al mejor de mi conocimiento y la creencia.)

SIGNATURE: (La Firma del solicitante) *

Type your first and last name here.

DATE SIGNED: (Fecha) *

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Supporting Documents

Utility Application for Extension (51 KB)

Utility Application for Extension

Supporting Documents

Contact Information