STL County Residents

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.

You must fill out the Affidavit section at the bottom of this form. The individual filling out the form is the “Client”. “Public Utility Assistance” is the amount of assistance you are asking Heatupstlouis.org to provide.

Application for Heat Up St. Louis County and two Benefits Affidavits

"*" indicates required fields

Proof of Income: Copy of last three current paycheck stubs, SSI, Social Security, Unemployment, Pension Awards Letter, OFFICIAL Child Support Form, etc. Upload Document to this form or FAX to 314-454-3180 or Email scanned documents to [email protected] or Drop off at 8960 Jennings Station Road, 63136, or Suite 111, 1408 North Kingshighway, 63112 in the mail slot. 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.

Select the number of people 18 or older living in the household.

Name of Person 1

First Last

Date of Birth of Person 1

Last 4-Digits of Social Security Number of Person 1*

Student or Employee for Person 1

Cell Phone of Person 1

Name of Person 2

First Last

Date of Birth of Person 2

Last 4-Digits of Social Security Number of Person 2*

Student or Employee for Person 2

Cell Phone # of Person 2

Name of Person 3

First Last

Date of Birth of Person 3

Last 4-Digits of Social Security Number of Person 3*

Student or Employee for Person 3

Cell Phone # of Person 3

Name of Person 4

First Last

Date of Birth of Person 4

Last 4-Digits of Social Security Number of Person 4*

Student or Employee for Person 4

Cell Phone # of Person 4

Name of Person 5

First Last

Date of Birth of Person 5

Last 4-Digits of Social Security Number of Person 5*

Student or Employee for Person 5

Cell Phone # of Person 5

Name of Person 6

First Last

Date of Birth of Person 6

Last 4-Digits of Social Security Number of Person 6*

Student or 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"

Other Reason For Contact

Membership

Donation

Event

Media

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 proceed to the COUNTY DUPLICATION OF BENEFITS SELF-CERTIFICATION AFFIDAVIT. It is mandated below.

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

Do not delete

Max. file size: 10 MB.

PROOF OF INCOME FIELD UPLOAD*

Drop files here or

Max. file size: 10 MB.

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

Proof of Income: Copy of 3 current check stubs, SSI, Social Security, Unemployment, Pension Awards Letter, OFFICIAL Child Support Form, etc. Upload Document to this form or FAX to 314-454-3180 or Email scanned documents to [email protected] or Drop off at 8960 Jennings Station Road, 63136, or Suite 111, 1408 North Kingshighway, 63112 in the mail slot. NO SCREENSHOTS! Thank you

DUPLICATION OF BENEFITS SELF-CERTIFICATION AFFIDAVIT - St. Louis County DHS

Name of Client

First Last

Address of Client

Street Address City State ZIP Code

1. Affidavit Statement - Select which applies*

I agree to the affidavit statement. I operate as an individual/ sole proprietorship.

I agree to the affidavit statement. I am a duly authorized signatory and representative of the entity named below.

I make this affidavit in connection with an award granted through St. Louls County's CARES CDBG-CV Program (the "Program"), submitted by "Recipient"), located at (the The Program is funded by the U.S. Department of Housing and Urban Development with a supplemental appropriation from the Community Development Block Grant-CARES (CDBG-CV) - The Coronavirus Ald, Rellef, and Economic Security Act of 2020 (CARES Act).

4. The Recipient and/or the organization providing services can produce documentation to support costs incurred and/or loss of expenses related to the Coronavirus/COVID-19 pandemic in the amount of*

DO NOT FILL OUT! THIS BLOCK IS FOR HEAT UP SAINT LOUIS.

Client Signature*

Client Name*

Mr. Mrs. Ms. 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 County and two Benefits Affidavits

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

Certification of Zero Income Self Affidavit

DUPLICATION OF BENEFITS SELF-CERTIFICATION AFFIDAVIT - St. Louis County DHS

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 County Residents

Application for Heat Up St. Louis County and two Benefits Affidavits

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

Certification of Zero Income Self Affidavit

DUPLICATION OF BENEFITS SELF-CERTIFICATION AFFIDAVIT - St. Louis County DHS

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!