Utility Assistance | The Senior Source

Name*

First Last

Phone*

I Listed My...

Home Phone
Cell Phone

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Gender*

Female
Male
Transgender
Other

Marital Satus*

Married
Single
Widowed
Separated
Divorced

Ethnicity*

Are You a Veteran?*

Yes
No
Prefer not to say

If You are a Veteran, Which Branch?

How Many People Live in Your Household?*

Total Household Income*

I need assistance with TXU

Yes
No

If you answered YES, you need assistance with TXU, what is your TXU account number?

I need assistance with Atmos

Yes
No

If you answered YES, you need assistance with Atmos, what is your Atmos account number?

I need assistance with Ambit

Yes
No

If you answered YES, you need assistance with Ambit, what is your Ambit account number?

I need assistance with Garland Power & Light

Yes
No

If you answered YES, you need assistance with Garland Power & Light, what is your Garland Power & Light account number?

I need assistance with Dallas Water Utilities (only for usage dates in February 2021)

Yes
No

If you answered YES, you need assistance with Dallas Water Utilities, what is your Dallas Water Utilities account number?

Upload a picture of your ID along with a copy of your bill(s) you need assistance with*

Drop files here or

Consent*

Consent for Service

I hereby certify that all information provided by me is true and correct to the best of my knowledge. I also authorize the Elder Financial Safety Center at The Senior Source to contact my utility provider to obtain information regarding my account if necessary.

I understand that the Elder Financial Safety Center at The Senior Source provides utility assistance once a year, and if wanted, I can participate in other programs and services of the Center that can better my financial situation.

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