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2. Program Qualifications.

   To qualify for the one-time utility assistance, the account must be no more than $100.00 past due, not have received this funding within the last 12 months, and total household income shall not exceed the amounts shown on the Utility Assistance Program page.

4. First Name*
5. Last Name*
7. Service Location Address*
9. Email Address*
10. Phone Number*
12. Utility Account Number*
13. Number of People in Household*
15. Income Verification Document 1
16. Income Verification Document 2
17. Income Verification Document 3
18. Income Verification Document 4

22. Information you provide is material to your eligibility for receiving a benefit. Therefore, giving false or misleading answers in this application to obtain a discount on your utilities is a crime, punishable up to 6 months jail and/or $2,500 fine. (ORS 162.085).

    I hereby request utility assistance and have provided the City of Ashland with income verification documentation for all members of the household over the age of 16 by redacting secure information and uploading documents above or by regular mail (20 E Main St. Ashland, OR 97520). 

    I certify that the above information is true to the best of my knowledge.

24. Signature of Applicant (Type Name)*
25. Date*
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27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field