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2. EFSP UTILITY ASSISTANCE APPLICATION

   Funding for this grant (EFSP) was made possible by Lumber River United Way. Please ensure that before starting the application you carefully read over the eligibility requirements. NO payments will be made directly to individuals; payments will be made to the utility vendor.

4. ***Please read the EFSP Quick Reference and FAQ information linked below before Applying***

6. EFSP Quick Reference Guide for Utilities NON-METERED BILLS
   Quick Reference Guide for Utilities NON-METERED BILLS
7. EFSP Quick Reference Guide for Utilities METERED BILLS
   Quick Reference Guide for Utilities METERED BILLS
8. HHS Poverty Income Guidelines
   Poverty Income Guidelines
12. CLIENT INFORMATION:
14. Full Name*
15. Phone Number*
17. Account Number*
19. Email Address*
21. Service Street Address*
22. City*
24. State*
25. Zip Code:*
29. Name of Utility Company*
    -- Select One --Duke EnergyLumbee River Electric Membership Corp (LREMC)City of Raeford Water DepartmentHilcrest-Scurlock WaterHoke County Utility DepartmentOther (Provide Name in the Next Box)
30. Other:
32. Account Name/Identifier*
36. Income Eligibility ****MUST ATTACH PROOF OF INCOME or SUMMARY BELOW****
38. Persons In Household*
39. Household Income*
41. Persons with No Income Should Give a Brief Summary Describing Their Economic Circumstances.*
45. Certification

    The applicant of this form hereby attests that the name in which this application was completed in is also the registered customer at the listed physical address for the selected utility vendor. Applications must be completed in the name of the person who is listed as a customer by the utility.

47. Citizens must attach original past-due cut-off/shut-off notice below.
49. Past-Due, Cut-Off/Shut-Off Notice*
50. Utility Bill*
52. Proof of Income*
54. Signature of Applicant*
55. Date*
    Date
57. Signature of Hoke County Staff
58. Date
    Date
Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field