Utility and/or Mattress-Box Springs Disposal Assistance Programs

I am applying for:*

Utility Assistance
Utility Assistance PLUS Mattress-Box Springs Assistance
Mattress-Box Springs Assistance ONLY

Is your request a result of COVID?*

Yes
No

Applicants Name*

First Last

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Northglenn Utility Account Number:*

PLEASE READ BEFORE CONTINUING

ALL APPLICATIONS MUST BE COMPLETE IN ORDER TO BE CONSIDERED FOR FUNDING. THIS REQUIRES THAT ALL FIELDS WITHIN THIS APPLICATION MUST HAVE A RESPONSE AND A COPY OF YOUR MOST RECENT CITY OF NORTHGLENN UTILITY BILL IS ATTACHED, IF YOU ARE APPLYING FOR UTILITY ASSISTANCE and/or MATTRESS-BOX SPRINGS DISPOSAL ASSISTANCE. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.

How many people in your household?*

Household Profile

List all individuals living in the home including yourself, your spouse, all minor children, all adult children, roommates, other relatives living with you

First Name	Date of Birth	Age	Relationship to Applicant	Medical Insurance	Disabled	Monthly Income for This Person	Actions

There are no Household Members.

Type of Income

Fill in ALL applicable fields with monthly dollar amounts received by any and ALL members of your household, including yourself, your spouse, all minor children, all adult children, roommates, other relatives living with you

Employment/Salary/Wages	Monthly Amount	Self Employment Income	Monthly Amount	Unemployment	Monthly Amount	Social Security or SSI	Monthly Amount	Social Security Disability	Monthly Amount	Pension	Monthly Amount	VA Benefits	Monthly Amount	Child Support	Monthly Amount	Alimony	Monthly Amount	Legal Settlement	Monthly Amount	Other Sources of Income	Monthly Amount	Actions

There are no Incomes.

Type of Benefit

Fill in ALL applicable fields with monthly dollar amounts received by any and ALL members of your household:

Section 8	Monthly Amount	TANF	Monthly Amount	AND/OAP	Monthly Amount	Food Stamps	Monthly Amount	Other Benefits	Monthly Amount	Actions

There are no Benefits.

Expenses

Please explain how you are currently paying for the following items:

Lodging	Utilities	Food	Other	Actions

There are no Expenses.

How many dependents do you claim on your tax return?*

How long have you lived in Northglenn?*

Is your hardship due to medical expenses?*

Yes
No

If inability to pay your Northglenn Utility bill and/or Mattress-Box Springs disposal is due to a hardship related to medical issues or disability please explain (in detail)

Describe the circumstances which brought about the shortfall with your Utility expenses and/or Mattress-Box Springs disposal expenses (in detail)*

Utility Assistance

Do you need assistance with your Utility Bill?*

Yes
No

Total Amount Due on your Northglenn Utility Bill:*

(format is 0.00 - do not add dollar sign)

Amount Past Due:*

(format is 0.00 - do not add dollar sign)

What is your average Northglenn Utility bill on a monthly basis?*

(format is 0.00 - do not add dollar sign)

Do you have a payment arrangement?*

Yes
No

What is the dollar amount that you can pay towards your bill?*

(format is 0.00 - do not add dollar sign)

Have you received a disconnect notice or shut off notice?*

Yes
No

When are your utilities scheduled to be disconnected?*

What is your plan to pay future Northglenn Utility bills?*

Applications are reviewed at the beginning of each month, so applications must be submitted and received by the last business day of the month. Once the application has been received by the Northglenn Community Foundation (NCF), the application will be reviewed and grants will be awarded based on the NCF determination of need and available resources. You will be notified by mail about the status of your grant request after the applications are reviewed. The grants that are receiving funding will have the funds applied directly to the recipient’s City of Northglenn utility bill. If you have received a disconnect notice from the City of Northglenn, please contact the city immediately to establish a payment plan and then submit this application as soon as possible. Grants are awarded monthly; therefore, it is recommended that you make the appropriate financial arrangements.

Mattress/Box Springs Disposal Assistance:

Do you need assistance for Mattress-Box Springs disposal?*

Yes
No

Pick-up for Mattress-Box Springs items	Total Number of Pieces	Total Cost of Above Items	Dropped-off at Northglenn Yard Mulching Center	Total Number of Pieces	Total Cost of Above Items	Actions

There are no Mattress Assistances.

Northglenn Community Foundation will review your application and receipts. Grants will be awarded based on the NCF determination of need and available resources. You will be notified by mail about the status of your grant request after the applications are reviewed. The grants that are receiving funding will have the funds applied directly to the recipient’s City of Northglenn utility bill. NCF offering grant assistance for City services generally up to a maximum of $65.

Additional Assistance Offering

Are you in immediate need of clothing or small household items for family members?*

Yes
No

May the Northglenn Community Foundation share your story to help raise funds for this program?*

Your identity will remain confidential.

Yes
No

Are you a Veteran?*

Yes
No

Are you a widow/widower of a Veteran?*

Yes
No

If you are a Veteran or Veteran's widow/widower, do we have your permission to share your name and information with an organization that may be able to provide additional assistance?

Yes
No

I hereby certify that this information is correct to the best of my knowledge. I authorize the reproduction and verification of this information. I give my permission to the Northglenn Community Foundation to exchange information regarding my application with appropriate resources in order to process my request for assistance. I specifically authorize the City of Northglenn to provide any necessary information from my utility billing account with the City to the Northglenn Community Foundation. I understand that by doing so, I am waiving the protections otherwise available to me pursuant to C.R.S. 24-72-204(3) (a) (IX) regarding the confidentiality of such information. I recognize that the services provided on the part of the Northglenn Community Foundation are subject to available resources. I understand that the decision of the Northglenn Community Foundation Grant Assistance Program are final and may not be appealed; however, future applications may be submitted for consideration. Finally, I swear or affirm that I am a U.S. citizen or a permanent resident of the U.S. or lawfully present in the U.S. pursuant to federal law. I further acknowledge that making a false, fictitious, or fraudulent statement or representations in this sworn affidavit is punishable under criminal laws of Colorado.

Signature*

Please use a mouse, touchpad, or touchscreen to sign

ALL APPLICATIONS MUST BE COMPLETE IN ORDER TO BE CONSIDERED FOR FUNDING. THIS REQUIRES THAT ALL FIELDS WITHIN THIS APPLICATION MUST HAVE A RESPONSE AND THAT A COPY OF YOUR MOST RECENT CITY OF NORTHGLENN UTILITY BILL IS ATTACHED. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR FUNDING.

Utility and/or Mattress-Box Springs Disposal Assistance Programs