Form 032-03-0650-07-Eng - Fuel Assistance Application

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Commonwealth of Virginia - Department of Social Services
AGENCY USE ONLY:
Locality/FIPS____________________
Case #______________________________
ADAPT #_____________________________
Date Application Received____________________
Worker #____________________
FUEL ASSISTANCE APPLICATION
nd
nd
Applications are accepted the 2
Tuesday in October through the 2
Friday in November
PLEASE ANSWER ALL QUESTIONS COMPLETELY
In what city or county do you live?
__________________________________________
Name_______________________________________________________________________________________ SEX:
M
F 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____________________
1. CHECK either YES or NO to answer each of the following questions.
A. I received Fuel, Crisis or Cooling Assistance in the past 12 months. ___YES ___NO
B. I pay to heat my home. ___YES ___NO
C. Oil, kerosene, gas, coal, or wood is delivered to my home. ___YES ___NO
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 heating bills.
G. I live in Section 8 housing, HUD, subsidized housing, & regularly pay some or all of my heating bills.
B. I own or rent my home and do not pay a heating bill.
I. I live in one room in someone else's house.
C. I pay $__________ rent and also pay for heat separately.
L. I live in an institution, group home, treatment center or home for adults.
E. I pay $__________ rent & my heat is included in the rent payment.
P. I live rent-free in more than one room, house or apartment and pay for heat.
F. I live in subsidized housing, Section 8, HUD and occasionally pay
Q. I live in an emergency shelter.
excess usage charges.
3. Are all of the people in your household United States citizens? ____YES ____NO
If NO, who is not a citizen? _______________________________________________________
4. Is anyone in your household disabled? ____YES ____NO If YES, who is disabled? ______________________________________________________________________________
5. How many people live in your household? _________
In the table below, please list yourself first then list every person living in the home. Complete all of the information (including Social Security Number) for every person in the
home.
INCOME
LIST ALL SOURCES OF
RELATION
DATE
WORKING
GROSS
PAID
INCOME
TO PERSON
SOCIAL
OF BIRTH
weekly,
Earned Income (List the Name of
MONTHLY
NAME
ON LINE #1
SECURITY#
biweekly,
Employer/Company);
Yes
No
INCOME
semi-monthly,
Self-employment; Social Security; SSI;
(Y)
(N)
AMOUNT
monthly
Veterans Benefit; Child Support; etc.
Self
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032-03-0650-07- eng (09/15)

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