UAP Document Upload Form

This form should be completed by City of South Bend Utility Assistance Program (UAP) participants that have received notice that they are included in the UAP audit.

The UAP audit is a process conducted by the City to ensure that the program is being utilized effectively. An audit is a process which asks a random percentage of participants to provide more details about their application in order to ensure a significant proportion of participants are eligible for the program.

To read more about the UAP audit, including FAQs, click here to visit the website.

For customers who are not yet enrolled in UAP, click here to fill out the application.

Name*

First NameLast Name

Email

example@example.com

Water utility account number*

his can be found in the upper right corner of your South Bend Utilities bill above the account name or address. Example: 12-3456.789. Please enter all numbers without dashes or dots

Please upload your document*

Below is a document outlining which forms of documentation are acceptable

I agree to the following:*

I agree that the data contained in this form is subject to the City's Data Collection Policy and that applicant data may be subject to disclosure to the extent required by the Access to Public Records Act. (I.C. 5-14-3 et seq.) I also agree that the City may contact regarding program eligibility and status by email, SMS, phone call, or direct outreach using the information I have provided. Under penalty of perjury, I certify that the information presented in this certification is true and accurate to the best of my knowledge. By marking agree, I further understand that providing false representations herein constitutes an act of fraud.

City Of South Bend Data Collection Policy

UAP Audit: Document Upload Form