Household and Utility Information Survey Entergy Utility Assitance Application Question Title * 1. Please provide your first and last name. Question Title * 2. Please provide the account holder's date of birth. Question Title * 3. Please provide your email address. Question Title * 4. Please provide your phone number. Question Title * 5. How many people live in your household? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 or more Question Title * 6. Do you or anyone in your household have a disability? Yes No Question Title * 7. What is the total annual income of all earners in the household? Question Title * 8. How many income earners over the age of 18 are in the household? 0 1 2 3 4 5 or more Question Title * 9. Please provide your utility service address. Question Title * 10. Please provide your Entergy account number. Question Title * 11. Is this Entergy account in your name? Yes No Question Title * 12. Documentation- Proof of Residency Question Title * 13. Documentation- Proof of Income (Earner 1) Question Title * 14. Proof of Income- Earner 2 Question Title * 15. Proof of Income- Earner 3 Question Title * 16. Proof of Income- Earner 4 Question Title * 17. Proof of Income- Earner 5 If you have more than five income earners, we will reach out to you for additional documentation. Done