2025 CAO UTILITY ASSISTANCE PROGRAM

CAO of WNY

Adult Services Division
CAO UTILITY ASSISTANCE PROGRAM
PLEASE NOTE THE FOLLOWING:
- ALL UTILITY BILLS MUST MATCH THE NAME AND ID OF THE PERSON APPLYING
- WE DO NOT RESTORE SERVICE!
- WE DO NOT START SERVICE!
- YOU MUST HAVE A SOURCE OF INCOME
- Maximum amount of assistance is $300 per household. (You may apply for assistance with one bill or divide the assistance between two bills)
PLEASE NOTE: THIS APPLICATION WILL TAKE ABOUT 15-20 MINUTES TO COMPLETE. YOU WILL NOT HAVE THE ABILITY TO SAVE YOUR APPLICATION PROGRESS AND COME BACK LATER!

PLEASE HAVE PHOTOS OF ALL REQUIRED DOCUMENTATION READY TO UPLOAD:
- photo id (head of household)
- social security number (head of household)
- identification for additional household members
- proof of address
- proof of monthly household income (YOU MUST HAVE INCOME TO QUALIFY)
- utility bill(s)
Please be advised that this application is strictly confidential. Any information regarding sex, ethnicity; education or disability is gathered for reporting to funding sources only. This agency does not discriminate in any way in provision of services.
Head of Household
What is your name? *

First NameLast Name
What is your Date of Birth?*

MonthDayYear
Date
What is your current address?*

Address

Street Address Line 2

CityState / Province

Zip Code
What is your phone number? *
What is your email address?
example@example.com
What is your gender?*

FemaleMaleOther
How old are you?*

0-56-1314-1718-2425-4445-5455-5960-6465-7475+
Education Level*

Grades 0-8Grades 9-12HS Graduate/GED12th Grade + Some Post Secondary2 or 4 yr. College GraduateGraduate of Other Post Secondary School
Are you disabled?*
Do you have health insurance? *
What type of Health Insurance?

MedicaidMedicareState Health Insurance For AdultsState Children's Health Insurance ProgramMilitary Health CareDirect PurchaseEmployment Based
Ethnicity
Are you of Hispanic, Latin or Spanish Origin?*
What is your race?*

American Indian or Alaska NativeAsianBlack/African AmericanWhite/CaucasianOtherBi-Racial (any two or more above)
Are you active military personnel or veteran?*

VeteranActiveNone
What is your employment status?*

Employed Full TimeEmployed Part TimeMigrant Seasonal WorkerUnemployed (short-term 6 months or less)Unemployed long term (more than 6 months)Unemployed (not in labor force)Retired
What is your household makeup?*

Single PersonTwo Adults NO ChildrenSingle Parent FemaleSingle Parent MaleTwo Parent HouseholdNon-related Adults w/ChildrenMulti-generational HouseholdOther
How many people are in your household including yourself?*

Single PersonTwoThreeFourFiveSix or more
Do you rent or own?*

OwnRentOther Permanent HousingHomelessOther
What is your total monthly income? And what is the source?

Indicate the monthly amount received from each source. Skip the ones that are not applicable.
Employment ($ per month)
TANF/ Cash Assistance ($ per month)
SSI/Supplemental Security Income ($ per month)
Social Security Disability Compensation ($ per month)
VA Non-Service Connected Disability Pension ($ per month)
VA Service- Connected Disability Compensation ($ per month)
Private Disability Insurance ($ per month)
Workers Comp ($ per month)
Retirement Income From SS
Pension
Child Support
Alimony/Spousal Support ($ per month)
Unemployment Insurance
EITC ($ per month)
Other ($ per month)
TOTAL MONTHLY INCOME FROM ALL SOURCES (Add up the boxes above)*
Do you receive any Non Cash Benefits? (Please check all that apply)

SNAPWICHEAPHousing Choice VoucherPublic HousingPermanent Supportive HousingHUD-VASHChildcare VoucherAffordable Care Act SubsidyOther
Additional Household Members (complete questions for each household member)
Full Name
Gender
Date of Birth (month/date/year)

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Full Name
Gender
Date of Birth

MonthDayYear
Date
Disabled
Veteran
Relation to Head of Household
Verbal Attestation- Read to Client and get verbal confirmation
"To the best of my knowledge, the information that I provided during this interview is accurate and truthful."
Name of person completing this application
Today's Date

MonthDayYear
Date
Is there anything that you currently need assistance with?

HousingRent/MortgageHealth InsuranceEmploymentEmergency ServicesSocial ServicesFoodClothing/CoatsDay CareEducation (K-12)Senior ServicesCommunity DevelopmentTax AssistanceBaby NeedsOther
Utility Company #1*
Account Number #1*
Amount that you would like paid towards bill #1*
Utility Company #2
Amount Number #2
Amount that you would like paid towards bill #2
Required Documentation

"You are required to submit the following documents within the next 3 business days in order to complete your application. All photos must be clear and legible. Unfortunately, if we do not receive these documents by the deadline, your application will be automatically denied."
Photo Identification for the Head of Household *

Cancelof
Proof of Social Security Number for Head of Household *

Cancelof
Identification for Other Household Members (does not have to have a photo) PLEASE LAY ALL IDS ON A FLAT SURFACE AND TAKE ONE CLEAR PHOTO!

Cancelof
Proof of HOUSEHOLD income for the past 30 days (FOR ALL ADULTS AGES 18+)*

Cancelof
Proof of HOUSEHOLD income #2 for the past 30 days (FOR ALL ADULTS AGES 18+)

Cancelof
Utility Bill #1*

Cancelof
Utility Bill #2

Cancelof
Name of Person Submitting the Application*
Should be Empty:

CAO of WNY

CAO UTILITY ASSISTANCE PROGRAM

Head of Household

Ethnicity

What is your total monthly income? And what is the source?

Additional Household Members (complete questions for each household member)

Verbal Attestation- Read to Client and get verbal confirmation

Required Documentation