October: the program is open to senior &/or disabled and medically fragile householdsNovember: the program is also open to households with children 6 and underDecember: the program opens to all Clackamas County income eligible households Indicates required field My household is within Clackamas County. (For households not within Clackamas County, please call 211 for information on Energy Assistance in your area.) First Name Last Name Email Phone Secondary Phone optional Address Address Address Line 2 City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Mailing Address Mailing Address (if different) Mailing Address Line 2 City State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Preferred Language - Select -EnglishRussianSpanish Number of adults in the home over the age of 18 who have sporadic income from odd jobs, and/or an informal child support agreement, and/or zero income. - select - 01234567891011121314151617181920 I have not received unemployment within the last six months. I have experienced delays with claims, reduction of income, and/or have been quarantined. I am requesting assistance with the following utilities: Electric—PGE (Portland General Electric) Electric - PGE Radios I am current on my account. I have a disconnect notice. I am shut off. Electric—CUB (Canby Utility Board) Electric—CUB (Canby Utility Board) Radios I am current on my account. I have a disconnect notice. I am shut off. NW Natural NW Natural Radios I am current on my account. I have a disconnect notice. I am shut off. Oil Oil Radios I currently have a supply. I am low on my supply. I am out. Pellets Pellets Radios I currently have a supply. I am low on my supply. I am out. Propane Propane Radios I currently have a supply. I am low on my supply. I am out. Wood Wood Radios I currently have a supply. I am low on my supply. I am out. I understand this form completion and submission will add my name to the Energy Assistance waitlist. When my name comes to the top of the waiting list, I will be mailed an application. I agree to provide any and all documentation as required to determine eligibility. Submit
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