Applicant Name(Required)Please note: The Grant Applicant Name MUST BE THE SAME NAME that appears on the utility bill. First Last Date of Birth(Required) MM slash DD slash YYYY Address(Required)Please Note: Address MUST MATCH the service address on the utility bills Street Address Apartment Number City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)Email Address:(Required) Enter Email Confirm Email Gender(Required)SelectMaleFemaleOtherGender "Other" Please Specify:(Required)Ethnicity:(Required)Please select ALL that apply. To select more than option please hold the control button and click your additional choices.Hispanic/LatinxNot Hispanic/LatinxAmerican Indian/Native American/Native AlaskanAsianBlack/African AmericanMiddle Eastern/North AfricanNative Hawaiian/Other Pacific IslanderWhite/CaucasianOtherEthnicity "Other" Please Specify(Required)Total Number Of People In Household(Required)Household Composition:(Required)Please select ONE option that most closely fits your situation.SelectSingle person - senior age 60 & overSingle person - non-senior (age 59 & under)Single parent female with minor childrenSingle parent male with minor childrenSeniors only household (all members are age 60 & over)Adult only household (all members are age 18 - 59)Two-parent family with minor childrenMulti-generational (ex: children, parents & grandparents in the same household)Mixed household with non-related members living togetherProvide Your Total Household Income(Required)This field ONLY accepts numbersHousehold Income Listed Above is(Required)SelectPer MonthAnnuallyDo You Own Or Rent Your Dwelling?(Required)SelectOwnRentType of Heat Service Used(Required)SelectGas (National Grid)Electric (Con Edison)OilPropaneIs Your Heating Utility Currently Disconnected Or Shut Off?(Required)SelectYesNoDo you currently have a disconnect/shut-off notice in effect on your heating utility?(Required)SelectYesNoDocument UploadsIn this section, you will need to submit supporting documents for your grant application. Please agree to and follow the steps below to ensure your documents are received. Improper document submission will result in a delay in your request. How To Scan and Submit Your Documents(Required)How to scan documents on your iPhone or iPad You can use the Notes app to scan documents on your iPhone or iPad. 1. Open Notes and select a note or create a new one 2. Tap the Paperclip icon, then tap Scan Documents 3. Place your document in view of the camera 4. If your device is in Auto mode, your document will automatically scan. If you need to manually capture a scan, tap the Shutter button or press one of the Volume buttons. Then drag the corners to adjust the scan to fit the page, then tap Keep Scan. 5. Tap Save or add additional scans to the document. How to scan documents on Samsung phones or tablets You can use the camera to scan documents on your Samsung device. 1. Open the camera app 2. Point your camera at the document you want to scan 3. Tap the yellow 'T' icon 4. Choose the area you want to scan 5. Tap Save I Have Read The Instructions On How To Properly Submit My DocmentsUpload A Copy Of Your Drivers License/ID(Required)Please upload a photo of your Drivers License or ID. Select "choose file" and then find the photo on your computer or phone and select it to be uploaded.Max. file size: 128 MB.Scan & Upload Copies of Your THREE Most Recent Utility Bills(Required)Please scan and upload a copy of your THREE most recent utility bills. Select "choose file" and then find the files on your computer or phone and select them to be uploaded. Please note that all information MUST be visible in your scan. Blurry or unclear uploads will not be accepted and will delay the grant review process. Drop files here or Select files Max. file size: 128 MB, Max. files: 3. Payment Information:(Required)If your grant application is approved, do you wish to pick up a physical check from our offices or do you wish to have the grant deposited directly into your bank account? Please note, if using bank deposit, the bank account MUST be in the name of the person applying for this grant.SelectPick Up A CheckDirect Deposit (Bank Account Must Be In Applicants Name)Bank Name(Required)Bank Account Type:(Required)Choose OneChecking AccountSavings AccountBank Routing Number(Required)Confirm Bank Routing Number(Required)Bank Account Number(Required)Confirm Bank Account Number(Required)Is there any other information you would like to include to support your application?Consent(Required)I attest that all information I have provided is true and accurate. I understand that I am solely responsible for my heating utility, and the outcome of this application will not prevent a disconnection/shut-off of my service or restore my service if it has already been disconnected. I understand that if I do not meet the eligibility requirements of this application, I will not receive a grant. I understand that I may be required to submit additional documentation to determine my eligibility for a grant. I further understand that Catholic Charities of Staten Island reserves the exclusive right to accept or deny any grant application at its sole discretion, and that grant decisions will be made on a rolling basis. Timing will depend upon the number of applications received, and grant will close when all funds have been disbursed. I ConsentBy submitting this application, I agree to all the above.(Required) First Last Δ
