Cooling Assistance Application Form printable pdf download

Commonwealth of Virginia - Department of Social Services

AGENCY USE ONLY:

Locality/FIPS________________________________ Case #___________________________________

Date Application Received_______________________

Worker #_________________________________

COOLING ASSISTANCE APPLICATION

Applications accepted from June 15 through August 15

In what city or county do you live?

PLEASE ANSWER ALL QUESTIONS COMPLETELY

PART I

Name_______________________________________________________________________________________ SEX:

Are you Hispanic or Latino? ____YES ____NO

Last

First

Middle Initial

Race (Circle One)

1. White

2. Black or African American

3. American Indian or Alaskan Native

4. Asian

5. Native Hawaiian or other Pacific Islander

0. Other

Physical/Service Address_________________________________________________________City/State___________________________Zip__________ Day Phone: ______________

Mailing Address ________________________________________________________City/State___________________________Zip__________ Home Phone: ____________________

Directions to home _______________________________________________________________________________________________________Email Address___________________

PART II

1. What is your cooling need? (Check all that apply)

____A. Pick up portable fan

____B. Purchase/install window air conditioner

Do you have at least one working air conditioner in your home? ____YES ____NO

(You cannot receive a

window air conditioner if you already have a working air conditioner of any type in your home. The local agency may call you or visit your home to confirm you do not have a working air conditioner.)

____C. Repair central air conditioner or heat pump

____D. Payment of electric deposit

____E. Purchase/install ceiling, attic or whole house fan

____F. Repair ceiling, attic or whole house fan

____G. Payment of electric bill

____H. Self-pick-up/install window air conditioner

2. Circle the letter that best describes your present living situation. Read each one before you choose. Circle only one.

A. I own or am buying my home and pay all cooling bills.

G. I live in Section 8 housing, HUD, subsidized housing, & regularly pay some or all of my cooling bills.

B. I own or rent my home and do not pay a cooling bill.

I. I live in one room in someone else's house.

C. I pay rent and also pay for cooling separately.

L. I live in an institution, group home, treatment center or home for adults.

E. I pay rent & my cooling is included in the rent payment.

P. I live rent-free in more than one room, house or apartment and pay for heat/cooling.

F. I live in subsidized housing Section 8, HUD, Public Housing,

Q. I live in an emergency shelter or I am homeless. I have arranged to move into a house, apartment or more

and occasionally pay excess usage charges.

than one room.

3. Are all people in your household United States citizens?

___YES ___NO If no, who? _________________________________ What is their Alien Status?__________________

4. Is anyone in your household disabled?

___YES ___NO

If yes, who? _________________________________________________________________________________

5. How many people live in your household? #_________

6. Is anyone temporarily out of the home? ___YES ___NO

If yes, who? _____________________________________

Expected Date of Return? __________________________

List yourself first and every person living in the home. List the Social Security Number for everyone who lives in your home. Complete information for each person.

INCOME

RELATION

DATE

INCOME

PAID

LIST ALL SOURCES OF INCOME

SOCIAL

OF BIRTH

WORKING

AMOUNT

weekly,

Employer for earned income,