STL City Residents Application

Some Funds Are Subject to be Exhausted. If so, we will refer you to a partner, to see if you qualify for their funds. Proof of Income: Copy of Check Stub Year-to-Date, SSI, Social Security, Unemployment, Pension Awards Letter, OFFICIAL Child Support Form, etc.

IT’ S IMPORTANT TO INFORM YOUR UTILITY COMPANY, THAT YOU FILLED OUT AN ONLINE APPLICATION, AND ARE WAITING FOR A PLEDGE. THIS HOPEFULLY WILL BUY SOME TIME. THE STATEMENT MUST BE TRUTHFUL.

Application for Heat Up St. Louis City

"*" indicates required fields

Proof of Income: Copy of Check Stubs Year-to-Date (2 current gross paycheck stubs if paid biweekly, 4 current gross paycheck stubs if paid weekly), SSI, Social Security, Unemployment, Pension Awards Letter, OFFICIAL Child Support Form, etc. Upload Document to this form or FAX to 314-241-1860 or Email scanned documents to [email protected] or Drop off at 1520 Market Street, 63103, Lobby Lock-Box. NO SCREENSHOTS! Thank you

First & Last Name*

Address ( Street #, Street Name, Apt # if any)*

Zip Code*

City/State*

Date of Birth*

Age*

Please Select Your Race/Ethnicity*

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Hispanic or Latino*

Proof of Income*

Must select one

Last 4-Digits of Social Security Number*

Phone*

Email*

FILL IN EMPLOYMENT STATUS BELOW and have you been economically impacted by inflation due to COVID, if so how?*

Please Give NAME, PHONE NUMBER OF EMPLOYER, and SUPERVISOR if you were furloughed, terminated, or had hours reduced due to COVID. If this is a medical reason please give us your physician's name and number. This information will be kept confidential. Regardless you will still need to supply this information to receive Utility Assistance.*

Any additional people under 18 or older living in household? If so, list.

Any additional people 18 years or younger must be added to this application. If they are over 18, you must declare as a student or gainfully employed. If employed last 3 current payroll stubs with year-to-date-gross. SSA/SSI 1 2024 awards letter.

Enter (from 1 to 6) the number of additional people living in your household.

Please enter a number from 1 to 6.

Name of Person 1

First Last

Date Birth of Person 1

Last 4-Digits of Social Security Number of Person 1

Student of Employee for Person 1

Cell Phone # of Person 1

Name of Person 2

First Last

Date Birth of Person 2

Last 4-Digits of Social Security Number of Person 2

Student of Employee for Person 2

Cell Phone # of Person 2

Name of Person 3

First Last

Date Birth of Person 3

Last 4-Digits of Social Security Number of Person 3

Student of Employee for Person 3

Cell Phone # of Person 3

Name of Person 4

First Last

Date Birth of Person 4

Last 4-Digits of Social Security Number of Person 4

Student of Employee for Person 4

Cell Phone # of Person 4

Name of Person 5

First Last

Date Birth of Person 5

Last 4-Digits of Social Security Number of Person 5

Student of Employee for Person 5

Cell Phone # of Person 5

Name of Person 6

First Last

Date Birth of Person 6

Last 4-Digits of Social Security Number of Person 6

Student of Employee for Person 6

Cell Phone # of Person 6

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First Name

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Last Name

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Last 4 Digits of SSN

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Date of Birth

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Choose one

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Mobile Phone Number

Reason for Contacting Us*

Request For Utilities

Other

If utility help is needed you MUST select "Request For Utilities"

Utility Company*

Utility Account Number*

Utility Amount Due*

Number of Household Occupants*

Current Monthly GROSS Income*

Pension, TANF, Disability, Social Security, or Unemployment, etc. Monthly Amount*

Disconnection Date*

Message*

Certification of Zero Income Self Affidavit

To be completed by an adult head of household member, who is claiming zero income from any source. ONLY FILL OUT IF YOU HAVE ZERO INCOME! If you have an income then proceed to the mandated Staff's Applicant Duplication of Benefits Certification.

Name

First Last

Address

Street Address City State ZIP Code

I hereby certify that I do not individually receive income from any of the following sources:
a. Wages from employment (including commissions, tips, bonuses, fees, ect.);
b. Income from operation of a business;
c. Rental income from real or personal property;
d. Interest or dividends from assets;
e. Social Security payments, annuities, insurance policies, retirement funds, pensions, or death benefits;
f. Unemployment or disability payments;
g. Public assistance payments;
h. Periodic allowance such as alimony, child support, or gifts received from person not living in my household;
i. Sales from self-employed resources (Avon, Mary Kay, Shaklee, etc.);
j. Any other source not named above.

Choose one:

Currently, I have no income of any kind and while I am seeking employment, these is no definite job offer at this time.

Currently, I have no income of any kind and I will not be seeking employment at this time, as I'm disabled, unemployed, or due to a medical condition.

I will be using the following sources of funds to pay for utility and other necessities:

Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. The undersigned further understand(s) that providing false representation herein constitutes an act of fraud. False, misleading or incomplete information may result in the termination or repayment of the Heat-Up St. Louis Inc. pledge.

Signature

Name

First Last

Date

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Do not delete

Accepted file types: jpg, pdf, png, , Max. file size: 8 MB.

PROOF OF INCOME FIELD UPLOAD*

Drop files here or

Accepted file types: jpg, pdf, png, tiff, Max. file size: 8 MB.

Press "Choose File" to select the document you would like to upload.

Proof of Income: Copy of Check Stub Year-to-Date, SSI, Social Security, Unemployment, Pension Awards Letter, OFFICIAL Child Support Form, etc. Upload Document to this form or FAX to 314-241-1860 or Email scanned documents to [email protected] or Drop off at 1520 Market Street, 63103, Lobby Lock-Box. NO SCREENSHOTS! Thank you

Staff's Applicant Duplication of Benefits Certification

This form must be submitted before submitting your request for Utility Assistance.

Certification Statement*

I, (Name stated above) state under penalty of perjury, that I reside at the following address (Address stated above) of the City of St. Louis, Missouri and certify I, (including all members of my household),

A. have not received utility assistance (or have an application pending) from another organization or agency, private or public, for the utility fees to be covered by the assistance to be received from Heat Up St. Louis, Inc.

B. have received utility assistance (or have an application pending) from another organization or agency, private or public, for the utility fees to be covered by the assistance to be received from Heat Up St. Louis, Inc.

If "B" is selected, indicate organization/agency providing assistance and the amount below:

Date*

Signature - I certify that the information that I have provided above is an accurate and complete disclosure. This includes the verification of my monthly/annual income, assistance, and employment status. If there are any inconsistencies with the information provided I understand that I may be required to repay any assistance received and may be subject to further penalty, including prosecution.*

FOR STAFF USE ONLY:

This section is only for staff members of Heat Up St. Louis, Inc. DO NOT FILL in this portion unless approved by Heat Up St. Louis, Inc.

I, (select option below) state under penalty of perjury, the following:

Staff, board, or consultant

I have reviewed the utility portal, and took note that the above client:

has not received local funds (i.e., Ameren, Spire, or City funds not deemed federal) within the past 90 days;

has in fact received local funds (i.e., Ameren, Spire, or City funds not deemed federal) within the past 90 days from various agencies, and they are as listed below.

Name, Amount received, and Date received

Signed by In-take Worker

Approved by

First Last

Date

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Welcome to Heat Up St. Louis!

5 Easy Ways to Give

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,
St. Louis, MO 63188
or click here for SECURE online donations

5 Easy Ways to Give.

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868, St. Louis, MO 63188
or click here for SECURE online donations

URGENT: We are only helping with Ameren bills NOW. Go to partnering agency on our website for agencies with LIHEAP funds for SPIRE BILLS help!

5 Easy Ways to Give

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,
St. Louis, MO 63188
or click here for SECURE online donations

Welcome to Heat Up St. Louis!

URGENT: We are only helping
with Ameren bills NOW.

Go to partnering agency on our website
for agencies with LIHEAP funds for SPIRE help!

Application for Heat Up St. Louis City

Any additional people under 18 or older living in household? If so, list.

Certification of Zero Income Self Affidavit

Staff's Applicant Duplication of Benefits Certification

FOR STAFF USE ONLY:

The above document must be reviewed and completed by the Heat-Up St. Louis staff for audits.

Welcome to Heat Up St. Louis!

5 Easy Ways to Give

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,St. Louis, MO 63188or click here for SECURE online donations

5 Easy Ways to Give.

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868, St. Louis, MO 63188or click here for SECURE online donations

URGENT: We are only helping with Ameren bills NOW. Go to partnering agency on our website for agencies with LIHEAP funds for SPIRE BILLS help!

5 Easy Ways to Give

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,St. Louis, MO 63188or click here for SECURE online donations

Welcome to Heat Up St. Louis!

URGENT: We are only helping with Ameren bills NOW.

Go to partnering agency on our websitefor agencies with LIHEAP funds for SPIRE help!

STL City Residents Application

Application for Heat Up St. Louis City

Any additional people under 18 or older living in household? If so, list.

Certification of Zero Income Self Affidavit

Staff's Applicant Duplication of Benefits Certification

FOR STAFF USE ONLY:

The above document must be reviewed and completed by the Heat-Up St. Louis staff for audits.

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,
St. Louis, MO 63188
or click here for SECURE online donations

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868, St. Louis, MO 63188
or click here for SECURE online donations

Heat Up St. Louis, c/o Commerce Bank, P.O. Box 868,
St. Louis, MO 63188
or click here for SECURE online donations

URGENT: We are only helping
with Ameren bills NOW.

Go to partnering agency on our website
for agencies with LIHEAP funds for SPIRE help!