Utility Assistance Application

If you need help filling out the form, please call the Community Health Coalition at (919) 470-8680, Mondays or Tuesdays, 10am - 4pm EST.

Print PDF form or submit online form below.


Beginning your Application – The following documents must be submitted when you apply.

  • Identification – The applicant or the co-applicant must provide identification (ID) in order to be considered for assistance. Photo ID is preferred, such as a driver’s license, state ID card, military ID card, or any passport. Many other forms of ID can also be used, such as a birth certificate, a Medicaid or Medicare card, a signed Social Security card or an ID card issued by an employer or religious organization/place of worship.

  • Proof of Residence – The applicant must provide proof that they live in the rental unit/home listed on the application; this could include a utility bill in the applicant’s or co-applicant’s name or identification that shows the same address as the rental unit/home.

  • Copy of your lease agreement and utility bills.

  • Landlord contact information

  • Long Term Disability Documentation (if applicable)

  • Signed Affidavit (If short-term disability, we need a statement by the applicant declaring short-term disability and reasoning behind it)

  • Utility Assistance - If you are applying for utility assistance, please be ready to provide current copies or photos of utility bills, late payment notices or payment plan documents.


Utilities eligible for assistance include:

  • Electric/Energy

  • Gas/Propane for home use (not for gas grills)

  • Water/Sewage

Receiving Assistance
If the applicant is selected, the Program will pay the utility companies directly. Before this happens, the applicant must submit the aforementioned documents and sign the forms that will be provided by the Program.

CHC Funding Award Process

  1. Eligible applicants are contacted by a CHC Staff Member to confirm applicant information and gather any additional information or documents needed to complete the application process.

  2. Once the application information is complete, the amount of assistance is calculated.

  3. Applicants will be notified of the award amount.

  4. For utility assistance, applicants receive a letter for each type of utility assistance requested whether approved or not.

  5. Payment is made directly to the utility providers.