If your problem is not about a utility (gas, electric, or any other utility), use a different application.

MJP will need to speak with you on the telephone or in person.  MJP will need to verify your eligibility for services and may need to gather more information about your situation.

Your E-mail address
Only provide an email address if you are the only person who has access to it or will be safe if others may see your email.
First name *
Middle name
Last name *
Maiden Name
Alias or Other Names You Go By
Date of Birth *
Street Address *
Address line 2
City *
Zip Code *
Home phone #
Work phone #
Cell phone #
The best phone number for us to call

Is it safe for us to call at this number? *

Is it safe for us to leave a message at this number? *

Best time to reach you, Monday through Friday between 9 a.m. and 4 p.m.
Please describe any special instructions or information we need to know about how to contact you or the person for whom you are applying for services
If you are submitting this application for another person, please tell us your name and your relationship to the applicant (family member, service provider, etc.)
Provide the name of the person or company with whom you have the dispute
Now we need to know how many people are in your household. In answering questions that follow, you must include all persons who are supported by you or who contribute to the support of your household whether or not they are related to you.
How many persons age 18 and older live in your household. (Include yourself)
How many persons under the age 18 live in your household.
Is anyone in this household currently a victim of domestic violence?

Person Receiving Income *
Income source *
Gross income amount for this source *
How often is this amount received *

Person receiving income
Income Source
Gross income amount for this source
How often is this amount received

Other income information not listed above (Include who receives, from where, how much and how often)

Please select all asset types owned by all persons in the household *

Value of assets *
How did you hear about us?
I am having problems with
Natural Gas Service
Name of company
Propane Gas Service
Name of company
Electric Service
Name of company
Name of company
Name of company
Which of the following describes the situation you are in
My service was shut off
When did this happen?
I am about to have my service shut off.
What date?
I can not pay my bill
Why not?
Select from other problems below

Other issue not listed above
We provide mostly information, referrals, advice and some brief legal help. We do not usually provide representation. In reply to your intake we may: give you information and materials only, or offer some legal advise or brief assistance.
To refer your case for further help or possible representation we need your permission to share information about your case with: Community Legal Aid, or a private volunteer attorney, or other legal Services program that covers your area.
By submitting this application, you agree to these terms.
Have you or anyone in your household served in the military?

What is your race or ethnicity?
Enter dollars per hour
How many hours do you work per week?
Enter this number in the monthly column.

Calculator figures "Dollar Per Hour" x "Hours Per Week" x 4.33 weeks in a month.

Income includes, but is not limited to: money, wages, salaries before any deductions, income for self-employment after deductions for business or farm expenses; regular payments from governmental programs for low income persons or persons with disabilities; social security payments; unemployment and worker's compensation payments; strike benefits from union funds; veterans benefits; training stipends, alimony; child support payments; military family allotments; public or private employee pensions; regular insurance or annuity payments; income from dividends, interest, rent, royalties or from estate trusts; and other regular or recurring sources of financial support that are currently and actually available.

Do not include value of food or rent received by you in lieu of wages; money withdrawn from the bank; tax refunds; gifts; compensation and/or one-time insurance payments for injuries sustained; non-cash benefits; and up to $2000 per year of funds received by individual Native Americans that is derived from Indian trust income or other distribution exempt by statue.