Utility Support Application Request

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

Preferred Language

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.

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 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.

Utility Support Application Request

I am requesting assistance with the following utilities:

SHORTCUTS

ELECTED OFFICIALS

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