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United Way of Gaston County

Rdavis@unitedwaygaston.org

200 E. Franklin Blvd. Gastonia, NC 28052

704-864-4554 ext. 104

Emergency Utility Payment Assistance Application

Tell us about you:

Full Name

Current Mailing Address

Residence Address

Date of Birth

For Which Utility/ies are You Seeking Financial Assistance?

CONSENT and RELEASE FORM

1)  When you apply at the United Way of Gaston County for assistance, we record the names, birth dates, social security numbers, and addresses of everyone in your household.  It is your responsibility to provide this information and any other documentation we deem necessary to make a decision about your request.

2)  This information may be shared with other organizations and service providers in our community.  Organizations that we coordinate services and resources with include, but are not limited to, Gaston County Dept. of Health and Human Services, the Salvation Army, Crisis Assistance Ministries, and area churches.

3) In order to help you, we may also need to contact your landlord, mortgage holder, utility company, Oil Company, employer, or any other resource providers for any reasonable purpose to help make a decision about your application and resolve your crisis.

4) If you contact a church or other organization for help, either now or in the months to come, that church may call the United Way to verify your situation.  By signing below, you give us permission to share information in your file with that church or organization.

5) I understand that by signing below, I am giving the United Way of Gaston County permission to obtain information pertaining to my household from the Gaston County Department of Health and Human Services.

6) The United Way reserves the right to refuse its services (both now and in the future) to anyone under or appearing to be under the influence of alcohol and /or drugs, displaying a rude and/or threatening behavior or to any person who gives false, fraudulent, or misleading information to the United Way for the purpose of obtaining assistance.

7) I certify that all information submitted/provided on this application is correct, to the best of my knowledge.

You have the right not to permit us to share any information with the organizations, businesses, and resources listed above, however, if you choose not to sign this Consent and Release Form, the United Way cannot help you.

This Consent and Release Form is valid for two years from the last date signed.  If you wish to revoke this consent and release, please contact our office.

*I authorize the United Way to provide information to the above stated agencies and resources for the purpose of verifying information, determining the amounts required, committing funds, and paying bills in order to act on my application and in response to other organizations which I have approached for help.

Sign Here

Choose how to sign

Duplication of Benefits Certification (Upload File Here)

The Duplication of Benefits Certification can be downloaded from the following web site:

 Duplication_of_Benefits_Certification_Fillable.pdf (cityofgastonia.com)

Income Self-Certification Form (Upload File Here)

The Income Self-Certification form can be downloaded from the following web site:

Information about CDBG Self Certification Form (cityofgastonia.com)

Applicant's Most Recent W-2 (Upload File Here)

Copy(ies) of Utility Bill(s) Seeking Payment Assistance (Upload File Here)

(If Applicable) Applicant's Most Recent Pay Stub (Upload File Here)

(If Applicable) Applicant's Most Recent Tax Return (Upload File Here)

(If Applicable) Applicant's Most Recent Bank Statement (Upload File Here)

(If Applicable) Court Ordered Child Support Documentation - Past Twelve (12) Months of Payments (Upload File Here)

(If Applicable) Most Recent Benefits Letter (2021) (Upload File Here)

(If Applicable) SSA-1099 - Disability Tax Form (Upload File Here)