Economic Opportunity Agency of Washington County

    614 E. Emma Ave., Ste. M401

    Springdale, AR 72764

    (479) 872-7479

    EOA WATER UTILITY ASSISTANCE APPLICATION

    ELIGIBILITY FOR WATER UTILITY ASSISTANCE (One-time Payment of Up to $100 Paid Directly to Water Utility Supplier)

    To be eligible for the EOA Water Utility Assistance Program, you must live in Washington County, your household income must be at or below 125% of the federal poverty guidelines, and you must have a Past Due Water Bill or Disconnect Notice. You also must provide proof of income for all household members 18 and older. Applications cannot be processed without complete information and supporting documentation.

    SUPPORTING DOCUMENTATION NEEDED TO APPLY

    • Driver's License or Photo ID
    • Proof of Income for Previous Month for all Household Members (Including Pay Stubs; Self-Employment Income; Social Security Income (SSA);
      Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); Child Support; TEA; Alimony; Unemployment benefits; Worker's Compensation; Veterans Benefits; Retirement Benefits, etc.)
    • Water Bill or Disconnect Notice
    • Social Security Number

    COMPLETING THIS APPLCIATION

    APPLICANT: All Sections of this form must be completed in order to determine your eligibility. Failure to complete this application and provide required documentation WILL delay the processing of your application. To qualify for the program, applicants must meet State eligibility requirements.

    APPLICANT INFORMATION




    HOUSEHOLD INFORMATION



    Race: I =American Indian/Alaskan Native, A =Asian, B =Black or African American, P =Native Hawaiian or other Pacific Islander, W =White, MR =Multi-Race, O =Other, NR =Choose not to respond

    Gender: M =Male, F =Female, NR =Choose not to respond

    Education: 8=0-8thGrade, NG=9-12 Non-Graduate, HSG=High School Graduate, GED=GED, SC=Some College or Post-Secondary CD =2 or 4 year College Degree, GD =Graduate Degree or above

    Name(s) of Household Members Relationship to Applicant Date of Birth MM/DD/YYYY Veteran
    Yes or No
    Active Military
    Yes or No
    Disability
    Yes or No
    Hispanic = Yes
    Not Hispanic = No
    See the Codes Above
    Race Gender Education Health Insurance Yes or No

    HOUSEHOLD NON-CASH BENEFITS

    Check any benefit that you or your household currently receive:

    HOUSEHOLD INCOME

    List the monthly amount of any income that you or your household currently receives. Please use gross income. Gross income is what you earn before taxes and deductions.

    Source of Income Applicant Additional Household Member Additional Household Member Additional Household Member
    Employment (Adults Only) $ $ $ $
    Self-Employment (Adults Only) $ $ $ $
    TANF $ $ $ $
    Child Support/ Alimony $ $ $ $
    Supplemental Security Income (SSI) $ $ $ $
    Social Security Disability (SSDI) $ $ $ $
    Social Security Retirement $ $ $ $
    VA Disability Compensation $ $ $ $
    VA Disability Pension $ $ $ $
    Retirement/Pension $ $ $ $
    Unemployment Insurance $ $ $ $
    Worker’s Compensation $ $ $ $
    Private Disability Insurance $ $ $ $
    Other: $ $ $ $

    My household has received NO income for the previous month.

    If you claim No Income, you will need two statements verifying you have zero income and documenting how you have paid living expenses.

    REASON FOR NEED OF RENTAL ASSISTANCE

    List the monthly amount of any income that you or your household currently receives. Please use gross income. Gross income is what you earn before taxes and deductions.

    The information I have provided is true and correct. I will provide documentation to verify my residency, the size of my household and income. I understand completion of this application does not guarantee that I will be eligible to receive rental assistance from CEO.










    APPLICANTS RIGHTS AND RESPONSIBILITIES

    I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in dec1s1on or delivery of services.

    I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.

    I authorize the contracted agency to release information relating to my application for Water Utility Assistance to my Water Utility Supplier to determine eligibility. I give permission to the Arkansas Department of Human Services to use the information provided on this form for purposes of research, evaluation, and analysis of the program.

    I understand that my utility service provider will have no control over the data disclosed pursuant to this consent, and will not be responsible for monitoring or taking any steps to ensure that the CSBG office maintains the confidentiality of the data or uses the data as authorized by you.

    I understand that no person may be denied assistance -on the basis of race, color, sex, age, handicap, religion, national origin, or poht1cal belief.

    I understand that my signature on this application authorizes the agency to make any investigation concerning me or any household member and/or use a copy as a release of information for securing information needed to determine my eligibility for services.

    I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding my circumstances, I must repay the cost of any assistance and may face a penalty of criminal prosecution.

    The information_given on this application is true to the best of my knowledge and belief.I understand that this form is signed subject to penalties for perjury.

    If your application is complete, please click the submit button below. You will be contacted to schedule a phone interview. Please gather the documents below, prior to your interview:

    • Driver's License or Photo ID
    • Water Bill or Disconnect Notice
    • Social Security Number
    • Proof of Income for Previous Month for Household Members 18 and older (Including Pay Stubs; Self-Employment Income; Social Security Income (SSA); Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); Child Support; TEA; Alimony; Unemployment benefits; Worker's
      Compensation; Veterans Benefits; Retirement Benefits, etc.)