Caring Neighbor Application - LaFollette Utilities Board

Name

This field is for validation purposes and should be left unchanged.

Account Name*

First Last

Account Number*

Home Number

Work Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Entire Application Must Be Completed Before It Is Processed

Please indicate the total number for the following

Household:

Elderly:

Handicapped:

Mortgage Payment $

Rent $

Public Housing $

Check Only What Applies To You

Please Complete For Each Person Living In Your Household

Name (Last, First, Middle)	Relationship to Head of Household

Please fill in details on the hardship you are experiencing.