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LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM APPLICATION 2 3 4 5 To apply for Energy Assistance, you must complete all questions front and back and sign at the red “X” . Be sure your correct and complete name and address is entered below. If incorrect, cross out and print correctly in space provided below. Please print. Your Social Security Number Phone number of applicant Are you or anyone in your household 60 years old or older? What is your sex? None Male Female Yes No 6 Do you understand English? If no, What language do you understand? 7 Yes No What Language FIRST NAME STREET ADDRESS CITY STATE ZIP CODE APARTMENT MIDDLE INITIAL LAST NAME DATE OF BIRTH Please complete this section if your name and address are not shown above or if the information shown is not correct. Show the name and address of the utility company or fuel dealer to whom you want payment sent. Send bills or receipts. SEE INSTRUCTIONS name of utility company or fuel dealer street number city state zip code 8 What is your main heating source - Send bills Electric Coal Fuel Oil Natural Gas Kerosene Propane or Bottled Gas Wood/Other 9 What is your second heating source - if any - Send bills SEE INSTRUCTIONS Electric Coal Fuel Oil Natural Gas Kerosene Propane or Bottled Gas Wood/Other 10 Are you An owner or are you buying your home Renting with heat included A roomer Other: __________________ Renting with heat not included Renting subsidized housing/ Section 8. Heat Included Social Security 7 Other: ______________ 10 Mark (x) all sources of income (including benefits) in your household and attach proof - if you receive Public Assistance (TANF or GA) or SSI, proof of these items does not need to be attached Veteran’s benefits Black lung 5 Interest/Dividends 9 Unemployment compensation SSI 3 6 Employment Public assistance 4 Child support 8 2 1 11 Commonwealth of Pennsylvania Department of Public Welfare 1 PWEA 1 8/07 YOUR NAME AND ADDRESS Your County Assistance Office address VENDOR ACCT. NUMBER CITIZEN RACE ETHNICITY VENDOR NO. MAIN FUEL 2ND FUEL INCOME SOURCE ANNUAL INCOME LIV. ARNG. DISAB. BENEFIT AMT. CRISIS CODE DELIV. DATE AUTH DATE REF. DISTRICT NO. IN H. H. COUNTY CASELOAD # WORKER I.D. INPUT CRISIS LIPEND DPW USE ONLY PROGRAM OPENS - November 5, 2007 or apply online at www.compass.state.pa.us
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12 Does anyone in your household receive financial assistance for a disability? Yes No 13 LIST THE PEOPLE WHO LIVE WITH YOU. START WITH YOURSELF. INCLUDE ALL CHILDREN AND ADULTS. INCLUDE RELATED ROOMERS. INCLUDE ALL UNRELATED ROOMERS WHO SHARE HOUSEHOLD EXPENSES. Using the codes below for the related fields, please provide the details for all individuals in your household: Use additional sheets, if needed.
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