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2. Utility Assistance may be awarded up to four (4) times a year. <br /> Have you received assistance from one of the following agencies within the past year? <br /> [-1 Yes F-1 No <br /> • Business and Community Lenders: BCL of Texas <br /> • Community Action <br /> • Communities in Schools <br /> • Salvation Army <br /> 3. If yes, please list the following information. <br /> Date of <br /> Application Agency Name Amount Received <br /> The information that I have provided is true and correct to the best of my knowledge and <br /> belief. <br /> Signature: Print Name: <br /> Date: <br /> Agency Use Only: <br /> Application Criteria:. <br /> F-]Low income (250% of the federal poverty level) families <br /> F-]Elderly (60 years or older) ❑ Disabled ❑ Military Veterans <br /> ❑Have children in the household age 5 years or younger <br /> Approved F-] Amount of Pledge: $ <br /> Denied ❑ Reason for denial: <br /> Staff <br /> Signature Date <br />