Request for Utility Assistance for South Louisville Residents

PLEASE READ THIS IMPORTANT INFORMATION FIRST:

We're glad you're our neighbor and we understand that life's challenges can become overwhelming. We wish we could help everyone that is going through a temporary crisis, but our funds are very limited. We will continue to do all that we can to help as man]y people as possible and appreciate your patience as we process this request.

PLEASE NOTE THAT BY FILLING OUT THIS FORM, YOU ARE NOT GUARANTEED FINANCIAL ASSISTANCE. Unfortunately, there are eligibility requirements for these funds and due to limited funding and high volume of requests, we cannot help everyone who applies. If we are able to assist you, we will reach out within one week of your intake with next steps. Please include an email address on your form if at all possible and check it frequently (including SPAM). Note: if we are able to assist you, we will be scheduling a time to meet with you for approximately an hour at our office.  If you do not hear from us after two weeks, you may apply again.

In the meantime, we encourage you to look for other resources and to request utility bill extensions.

WE ONLY SERVE NEIGHBORS IN 40214, 40215, 40209, 40118 and those families in 40208 who live south of Eastern Parkway/Industry Road as well as residents WEST of I-65 in 40219. Please only fill out this form if you live in one of these zip codes. BUT, if you live outside of our area, be aware that there is a community ministry in your area: https://www.louisvilleministries.org/

Your information below will be kept confidential! Please fill this form out as completely as possible. Missing information can delay our assistance.
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First Name *
Last Name *
Current Address *
Zipcode *
If OTHER: find your ministries at: louisvilleministries.org
Date of Birth *
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Last 4 digits of social security number (if available)
ONLY the last 4 numbers!  
Phone Number(s). *
Additional Phone Number and Name of Contact (Friend or family member who can reach you)
What is your email address or an email address where we can reach you?
What is the best way to contact you?
Check all that apply
Please READ AND RESPOND:  I authorize the South Louisville Ministries (SLCM) to gather and release information about me for the purpose of verifying my need for and/or my eligibility for assistance, for the purpose of securing services to help me improve my social and/or economic situation, and in order to help SLCM advocate for me with creditors and any others for which I need SLCM’s help (i.e.  LG&E, Community Winterhelp, Legal Aid, landlords, pharmacy, medical facilities, mortgage companies, churches, and other social service agencies…).   I further understand that my refusal to provide any or all of this information asked for in this form may result in my being denied services by the agency.   TYPE "YES-your name" below to agree.   *
TYPE "YES" and your name below to agree.
Total Number in Household *
Household Monthly Income for the last 30 days *
ALL sources of income for all the people that live there for last 30 days
Who lives in the household (check all that apply)
What crisis has occurred in your life that causes you to not be able to afford to pay this bill yourself.  (ie. childbirth, loss of job, car repairs, death in family, medical bills)             *
What is your most urgent need? *
Is your service currently connected? *
If disconnected, are you trying to pay an old bill in order to set up new service?
Clear selection
If it is an old bill, what is your old address?
Have you called the utility company to set up a payment plan?  (If not, you should do that immediately!) *
Did you get LIHEAP help this year? *
NOTE: There is a NEW Spring Subsidy program and you can apply here for additional help:  https://louisvilleky.itfrontdesk.com/apptonline/landing.html?client_code=LOUIMGOV
If you have an upcoming appointment at LIHEAP what is the date?
MM
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DD
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YYYY
If you need LG&E help, what is your account number?
NOTE: NO dashes are needed.  
If you need Water assistance, what is your account number? *
Note: funds are limited
What is your primary language?
Who is filling out this form? If you are filling this form out on behalf of the applicant, please leave your information in the comment section below. *
Other questions/comments/concerns:
Please let us know anything else about your situation that you think we should know or any questions that you have.
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