Eagle Mountain City Utility Assistance Application
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
City Account Number
*
Do you own or rent the property for which you are applying?
*
Own
Rent
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How many people live in your household?
*
1 person
2 people
3 people
4 people
5 people
6 people
7 people
8+ people
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Please select your household annual income (1 person)
Less than $66,750
More than $66,750
Please select your household annual income (2 people)
Less than $76,300
More than $76,300
Please select your household annual income (3 people)
Less than $85,850
More than $85,850
Please select your household annual income (4 people)
Less than $95,350
More than $95,350
Please select your household annual income (5 people)
Less than $58,020
More than $58,020
Please select your household annual income (6 people)
Less than $110,650
More than $110,650
Please select your household annual income (7 people)
Less than $118,250
More than $118,250
Please select your household annual income (8+ people)
Less than $125,900
More than $125,900
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Thank you for your interest in Eagle Mountain City's Utility Assistance Program. Please select submit below. Once submitted your application will be reviewed and you will receive notification via email of the application status.
Eagle Mountain City receives federal money for this program and as such, we are bound by the federal government's eligibility standards.
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How many members of your household receive ANY source of income?
*
Please Select
1
2
3
4
5
6
7
8+
Proof of ALL Income received by ALL household members in the month prior to the month of your application is required. Please upload a copy of MOST Recent paystubs or if unemployeed or receive other sources of income last years tax form for ALL members of your household members that receive any income. This is REQUIRED for application consideration.
*
Browse Files
Drag and drop files here
Choose a file
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of
If you rent the property for which you are applying you must provide a copy of your rental agreement. This is REQUIRED for application consideration.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please select your ethnicity:
*
Hispanic or Latino
Not Hispanic or Latino
Please select your race:
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other/Multi-Racial
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Submit
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Denial Reason
Please Select
Over Federal Income guidelines
Docs not provided or not valid
Name on app doesn't match owner utility account or rental agreement
This Page is for Eagle Mountain City Office Use Only
Application Status
Approved
Denied
Reviewed By (Name or Intitals
Reviewed Date
-
Month
-
Day
Year
Date Picker Icon
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