EITC Request Application – West

Bedford, Harrisburg, Huntingdon, Lancaster, Lewistown, Oxford, Shippensburg, or Waynesboro Area

Accepted May 1^st - August 1^st

Preference is given to programs that serve multiple communities in our service area.

Programs must be approved from DCED in order to receive funding.

After filling out the form below, please email the following to tlowry@ugi.com:

1) Completed Vendor Profile Form - click to download
2) Your W9 Form and any other supporting documentation we may need

Name of Organization

Which program are you applying for? Check all that apply.

EIO OSTC PKSO

Street Address

City

State

ZIP Code

Contact Person

Phone Number

Is your organization a 501(c)(3) registered non-profit organization?

Yes No

Have you received an EITC contribution from UGI previously?

Yes No

Have you previously participated in the EITC program?

Yes No

If you selected yes above, please attach your annual report (Appendix IV).

If you selected no above, please attach your program description.

Amount of Gift Requested

Please note if a UGI employee is actively involved in your organization.

Emergency Information

Have an Emergency?

Electric Information

Have an Emergency?

Emergency Information

Have an Emergency?

How can we help you?

EITC Request Application – West

Bedford, Harrisburg, Huntingdon, Lancaster, Lewistown, Oxford, Shippensburg, or Waynesboro Area

Accepted May 1^st - August 1^st

After filling out the form below, please email the following to tlowry@ugi.com:

Emergency Information

Have an Emergency?

Electric Information

Have an Emergency?

How can we help you?

Log Into Your Account

Emergency Information

Have an Emergency?

How can we help you?

Log Into Your Account

EITC Request Application – West

Bedford, Harrisburg, Huntingdon, Lancaster, Lewistown, Oxford, Shippensburg, or Waynesboro Area

Accepted May 1st - August 1st

After filling out the form below, please email the following to tlowry@ugi.com:

Accepted May 1^st - August 1^st