Project Deserve Application – Fill Out and Use

For office use only:

Project DESERVE Application PM ____/____/200__

This program provides assistance to current Westar Energy customers. Applications may ONLY be submitted by mail through the United States Postal Service. They must be postmarked between the 1st and 7th of the month. Any application with a postmark before the 1st or after the 7th will not be considered. Please see page 3 for other important information and requirements. Assistance is determined on a first-come first-served basis, based on the availability of funds, to those who demonstrate a financial need.

To be eligible for this program, a member of your household must meet one of the following categories:

Your address:

Street Address

City

State

Zip

County

Please indicate with a check () below why you need assistance with your bill:

 Not Enough Income Monthly  Loss of income  Unusually High Utility Bill  Unusually High Medical Bill

Other (please

explain)_____________________________________________________________________________

Please list the following information from your Westar bill:

Account number ____________________________ Total Bill Amount ____________

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Budget Information					Income Information
MONTHLY EXPENDITURES	Amount		Regular		Name of person	Source	Amount
	paid this		monthly
	month		expenses
Food							$
Household supplies (cleaning,
soap bleach, etc.)							$
Shelter (rent, mortgage, paid off)							$
Electricity							$
Gas/Heating (fuel, oil, wood)							$
Water/Sewer							$
Trash							$
Telephone					Monthly Income total		$
Clothing					Monthly Expenditures		$
Transportation (fares, gas, oil)
					IMPORTANT!
Property Insurance
Auto Insurance
Medical Insurance					Please include ALL household income
Life/Burial Insurance					sources.
					Source examples include:
Taxes (personal property, real
estate)					Employment, SSD, SSI, SS, TAF,
Medical/Dental/Drug expenses					Food Stamps, Unemployment,
					Worker Compensation, Child Support,
Personal needs (haircuts, laundry,
diapers, etc.)					Alimony, General Assistance (GA),
School costs (tuition, books)
					etc.
Recreation (cable, movies, trips,
cigarettes, lottery, gifts, etc.)					Each source requires official written
Other (child care, charity, alimony,
					verification.
church, etc.)
					Examples of verification include:
					paycheck stubs for last 30 days, letter
Credit Buying - car payments					from Social Security office (for current
or other loans, medical bills,
					year), printout from SRS, printout from
charge cards, appliances,
furniture, etc.					unemployment office, etc.
					DO NOT SEND ORIGINAL DOCUMENTS.
					SEND COPIES. ALL DOCUMENTS WILL
TOTALS					BE DESTROYED AFTER REVIEW.

Please read the next page (p. 3) very carefully.

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Required Verification

To have your application for assistance considered, written verification of your situation is required. Along with this signed application, you must provide COPIES of the following:

•Copies of current verification for each source of income in your household for the last 30 days

•Copy of your current Westar Energy bill

•Copy of photo ID for every adult in your household

DO NOT include originals as they will not be returned to you. All documents will be destroyed after review.

Notification Information

You will be notified, in writing, of our decision. Please allow up to 4 weeks to receive notification by mail. For those who are approved, payments will show as a credit on your Westar bill.

Please return completed application and verifications to:	American Red Cross
	Midway-Kansas Chapter
	Project DESERVE
	P.O. Box 3726
	Wichita, KS 67201

Please list the name of any helping agency or organization that helped you complete this application:

READ THE FOLLOWING CAREFULLY BEFORE SIGNING

My signature below means that I understand and agree to all of the following:

I understand it is my responsibility to provide current proof of all household income, a current copy of my bill and photo ID’s of all the adults in my household to determine my eligibility.

I understand I need to continue making regular payments to my energy provider and that any Project Deserve benefits which may be received do not take the place of my responsibility to pay the vendor.

I understand my eligibility will be determined under the Project Deserve guidelines.

I understand this assistance is available one time per year on a first-come, first-served basis to those who demonstrate a financial need.

I authorize my utility provider to release my payment history and other information to the American Red Cross. I also authorize the American Red Cross to release application information to my energy vendor.

I understand applications with incomplete information or verification will not be processed and will be destroyed.

I understand applications may ONLY be submitted by mail through the United States Postal Service and must be postmarked between the 1st and 7th of the month.

I certify that all information I have provided is complete and accurate.

( )

Signature of Adult Household Member

Date

Daytime phone number

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