Provide the name of all household residents at the above address over the age of 18. Please add one name per line; to add additional individuals, click the plus sign. Proof of Income for the last 30 days for all residents in the household must be included in the income section
Utility Assistance Agreement
The information you have provided for energy assistance will be used to determine if you are eligible for city of Pendleton Utility Assistance. The City of Pendleton Utility Assistance Program includes base water, base sewer, and water usage. It does not include any additional costs, including, but not limited to, the safety or street utility fees. This program is voluntary. If you choose to apply for assistance you must give all required information during application processing, and we may need to ask you for more information to determine eligibility.
I understand the information I provide to complete this application will be used to determine my eligibility for City of Pendleton Utility Assistance. I declare, under penalty of perjury, that the information I provided to complete this application is true, correct, and that any discounts received by me will be solely applied to my City of Pendleton Utility bill.
By typing my name below, I accept this as a signature giving consent for Helping Hand or CAPECO to share information related to my application, including, but not limited to, account(s), account number, account name, service address, and phone number with the City of Pendleton. I agree to hold harmless and/or release such organizations from and against any claims, losses, demands, or liability of any kind caused by or allegedly caused by such disclosure.
I authorize the City of Pendleton Utility Billing to release my account information to the service provider for the purposes of providing utility assistance for the current program year ending December 31. I am the account holder or the customer’s authorized agent for the City of Pendleton Utility Billing account(s) identified in this application.
