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Utility Assistance Form

Please complete this form if you need help with your utility bill. You must live in Birmingham- Jefferson or Shelby County, and upload a utility bill (power, water, or gas) with an address that matches your form.
Gentle Note: We know many families have been affected by the government shutdown, and we are praying for everyone. Please know we’re here if anyone simply needs someone to talk to. While we wish we could assist every family, our resources are limited, and selection is not guaranteed.
1.In order to process your request, please provide the following:(Required.)
2.Employment Verification: Are you (or a member of your household) a current or furloughed federal employee affected by the shutdown?(Required.)
3.Please upload one of the following to verify federal employment (you may redact personal information such as salary or ID numbers):

A recent federal employee ID badge
A recent federal pay stub (within 60 days)
A furlough or leave notice from your agency
An official letter or email confirming your shutdown status(Required.)
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4.Number of adults in household that are 65 and up?(Required.)
5.Number of children in household below 18?(Required.)
6.Has anyone in your household received utility assistance in the past 12 months? (Please select one)
7.Bill support request?(Required.)
8.Amount of assistance you are requesting? (Please note: Assistance cannot exceed $200)(Required.)
9.Are you the account holder on the utility bill?(Required.)
10.Please upload the bill (maximum assistance is $200). The upload must be legible. If you cannot upload the bill, please contact us at (205) 354-4830 for further instructions.
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11.I certify that I (or a member of my household) am a federal employee or contractor affected by the current government shutdown, and that the information provided is true and accurate to the best of my knowledge. I understand that this information will remain confidential and used only to verify eligibility for assistance.
12.Would you like someone from our ministry team to reach out for prayer or encouragement? (Optional)
13.Feel free to share anything else with us.