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January 16th

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Utility Application

  • APPLICATION CHECKLIST
    UTILITY & HEATER/ AC REPAIR

    ONLY COMPLETED APPLICATIONS. WITH REQUIRED DOCUMENTATION WILL BE ACCEPTED.

    (ADDITIONAL DOCUMENTATION IS AVAILABLE FOR ACCEPTANCE- SEE ALTERNATIVES ON PAGE 2)
    DOCUMENTATION IS AVAILABLE FOR ACCEPTANCE- SEE ALTERNATIVES ON PAGE 2)
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
  • NOTICE TO ALL CITY OF LUBBOCK UTIUTY CONSUMERS:

    IN ACCORDANCE WITH STATE AND FEDERAL REGULATIONS, PAYMENTS FOR WATER, STORM WATER, WASTEWATER, AND SCUD WASTE ARE NOT ALLOWABLE EXPENSES AND CAN NOT BE PAID BY COMPREHENSIVE ENERGY ASSISTANCE PROGRAM (CEAP) FUNDS. WE ARE UMITED TO PAVING ELECTRIC, NATURAL GAS, OR PROPANE ONLY.

    THE NON-ELECTRIC PORTION OF YOUR BILL MUST BE PAID OR PAYMENT ARRANGEMENTS MUST BE MADE BEFORE APPUCATION WILL BE ACCEPTED.

    REMINDER: Once the COMPLETED application is received with ALL supporting documents it will be processed in the order it was received, and by priority until your application is processed. You are responsible for your utility bills and any late fees applied. You will be notified by phone call or email if you qualify for assistance. All assistance is subject to the availability of funds.

    CALL 806-589-1907

  • **Applications for CEAP/LIHEAP cannot be processed without verifying the citizenship and identity for ALL household members. Applications cannot be accepted without the documentation for EVERYONE.**

    IDENTIFICATION INFORMATION

    TO VERIFY CITIZENSHIP EVERYONE 18 AND OLDER MUST PROVIDE:

    • ONE OF THE FOLLOWING:

      Birth certificate or birth record issued by appropriate State Bureau of Vital Statistics

      Undamaged US Passport or passport card (This verifies Citizenship and Identity)

    • OR PROVIDE TWO OF THE FOLLOWING:

      • Hospital birth certificate
      • U.S Census Record (1940 or prior)
      • Early School Records
      • Doctor’s records of post-natal care
      • Baptism certificate (Infant)
      • Family Bible Record
      • Form DS-10: Birth Affidavit
  • If an adult in the household is not listed as parent on the birth certificate of any of the children, we must have below identification information for that child.

    ADULT (18 YEARS AND OLDER) IDENTIFICATION

    • ONE OF THE FOLLOWING:

      • Texas Driver’s License or photo ID within two years of expiration date
      • Government employee ID
      • U/S Military or Military Dependent ID
      • Temporary driver’s license with photo
      • Out-Of-State driver’s license within 60 days of expiration
      • TDCJ ID card
      • Undamaged US Passport or passport card (This verifies Citizenship and Identity)
    • OR ONE OF THE FOLLOWING:

      • Social Security card (Actual card)
      • Voter registration care (Actual card)
      • Employee work ID
      • Student ID
      • Medicare or other health card
      • TDCJ parole or mandatory release certificate
      • W-2 or 1099 form
      • School Record (report cards)
      • Veteran Health ID card
      • Original or certified copy of marriage certificate or divorce decree
      • Current Texas motor vehicle registration or Title
  • NEIGHBORHOOD HOUSE
    1212 13TH STREET-SUITE 102, LUBBOCK
    806-589-1907

    UTILITY & HVAC/HEATER/AC REPAIR
    ASSISTANCE INFORMATION


    Applicant Information (please print)
  • (if different)
  • Household Demographics | (INCLUDE ALL PERSONS LIVING IN THE HOUSEHOLD.)
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
    • Date Format: MM slash DD slash YYYY
  • (IF ADDITIONAL SPACE IS NEEDED, PLEASE USE BACK OF AP PUCA TION.)
  • CUSTOMER RELEASE OF INFORMATION

    • Home
  • UTILITY COMPANY INFORMATION

    *Please provide the name of your utility companies if they apply to you and the account numbers for each*

  • *Excel Customers must provide copy of 1st bill of NON-Payment

  • “I authorize the Texas Department of Housing and Community Affairs, the City of Lubbock and its contracted agencies to solicit/verify information on my energy billing and consumption histories, both past and future, to the extent the information is used only to determine program eligibility and to provide data. By signing this authorization I also release, acquit and forever discharge the City of Lubbock from any and claims, demands, damages, attorney’s fees, costs, causes of action of whatsoever kind of nature, whether statutory provided or otherwise, arising out of any intentional or negligent misuse or theft of my energy/utility information by the City of Lubbock or its contracted agencies.”

    • Participants Signature
    • Date Format: MM slash DD slash YYYY
      Date
  • DECLARATION OF INCOME STATEMENT

  • State the gross income for household member, 18 years and older, who have documentation of the income received in the 30 days period prior to the date of application for assistance:

  • I certify that the above information is true and correct to the best of my knowledge and belief.

    I understand that information will be verified to the extent possible; and that I may be subject to prosecution for providing false or fraudulent information.

  • TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS

    Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/US National Applicant Certification Form for WAP and CEAP

    The program for which you are applying requires verification that you are a U.S. citizen, anon-citizen national, or a legal resident of the United States. Documentation of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non-citizens.

  • To add additional household members, use another copy of this form.

    I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION.

    • Applicant's Signature
    • Date Format: MM slash DD slash YYYY
      Date
    • Signature of agency staff certifying they verified the above documents
    • Print Staff Name
    • Date Format: MM slash DD slash YYYY
      Date
  • Call Us 24/7

    Call: 1-833-802-3678

    Text: 512-222-8783

    Email: [email protected]