EMERGENCY SHELTER GRANT(5)

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					EMERGENCY FOOD AND SHELTER PROGRAM SHAWNEE COUNTY METERED UTILITY VERIFICATION FORM PHASE: 23 CONTRACT PERIOD: October 1, 2004 to September 30, 2005
Client Name: Assistance must match name on utility bill. Amount of assistance: $ Social Security #:

Check #:

Metered utility assistance (attach copy of the bill and cancelled check): Utility Service Kansas Gas Service Westar Energy City of Topeka, Water Div. Kaw Valley Other (specify) Client on Level Payment Plan Yes No Yes No Yes No Yes No Yes No Amount

The attached utility bill charged to the Emergency Food and Shelter Program covers the dates of: to and was due on . Note: Payment cannot be paid anymore than five (5) days before the bill is due. The amount paid by my LRO is highlighted on the attached bill and covers only one (1) month.
Caseworker initials

The above requested information was not clearly stated on the attached bill, I have verified the above information with the utility company.

Staff Signature

Date

Client Signature

Date


				
Lingjuan Ma Lingjuan Ma
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