Utility Intake Questions Name: Today's Date: Phone Number: Alternate Phone Number: Email: Address (Must be Ottawa County): # of Adults (18+) in the home: # of children under 18: Whose name is the bill in? Does this person live with you currently? Yes No Is your bill past due? Yes No Have you received utility assistance from DHHS since October 1? Yes No Do you have a denial letter from DHHS? Yes No What is the household gross monthly income? Utility Information: Utility Company #1 Shut-Off Date Shut-Off Amount Total Amount Utility Company #2 Shut-Off Date Shut-Off Amount Total Amount Additional Notes:
