Form 032-03-0650-07-Eng - Fuel Assistance Application Page 2

6. CIRCLE ALL types of household income:

A. TANF

B. Social Security

C. SSI

D. Unemployment

E. Employment or Self-employed

G. General Relief

H. Veterans Benefits

N. Worker's Compensation

Q. Alimony or Child Support

U. Rental Income

W. Retirement Other: specify_______________________________

7. Do you receive payments from the Division of Child Support Enforcement? ___YES ____NO

How much? ________ Who pays the child support? _______________________

8. Does any household member receive SNAP benefits (formerly Food Stamps)? ___YES ____NO

If yes, case name___________________________________________________

9. Does any household member receive Medicaid? ___YES ___NO

If yes, case name______________________________________________________________________

10. Is Medicaid Home & Community-Based Care received? ___YES ____ NO

If yes, by whom? __________________________________ Patient pay amount is $______________

11. Does anyone pay for Medicare Part B___ or D ___ insurance? ___YES ____NO

If yes, who? ______________________________________ How much? $_________________

12. CIRCLE the type of equipment you use as the main heat source for your home. CIRCLE ONLY ONE.

A. Furnace

B. Radiator

C. Portable Heater

D. Vented Space Heater (heater with outside exhaust or Monitor system)

E. Baseboard

F. Heat Pump

G. Fireplace

H. Coal or Wood Stove

J. Cook stove

K. None

L. Unknown

13. CIRCLE the type of fuel you use to heat your home. CIRCLE ONLY ONE.

1. Electricity

2. Natural Gas

3. Oil (#2)

4. Clear Kerosene

0. Red Kerosene

5. Coal

6. Wood

7. Liquid Propane (LP)/Bottled Gas

14. Name and address of the company used for home heating: __________________________________________________________________________________________________

If you heat with electricity or natural gas, attach a copy of your current electric or gas bill. A Fuel Assistance payment can only be made if you owe a balance on your electric or

natural gas bill. Complete the following:

Account Name____________________________

Account Number_________________________

Who is responsible for paying the bill? ________________________

Is the payment made by an automatic debit/credit payment or monthly bank draft? ___YES ____NO

The following questions are for statistical purposes only. Your responses will not impact the processing of your application, your eligibility, or your benefit amount.

15. Name of the company used for electric service: ___________________________________________________________________________________________________________

Account Name_______________________________________________________________

Account Number_________________________________________________

16. Please describe your household’s current energy circumstances below:

□

Already Disconnected

Company: ____________________________________________________

Disconnect Date: _________________________________

□

Received Disconnect Notice

Company: ____________________________________________________

Date Disconnect Scheduled: ________________________

□

Prepay Electric Account

Balance of $25 or less? ___YES ____ NO

Account balance: $________________________________

□

Propane/Bottled Gas Tank

Less than 10% in tank? ___YES ____ NO

Size of your tank: _______

What is the percentage in your tank today? ____________%

□

Oil or Kerosene Tank

Less than 25 gallons in tank? ___YES ____ NO

Size of your tank: _______

How many gallons are in your tank today? _____________

□

How many days’ supply of coal or wood do you have left? _____________________________

Coal or Wood

Less than 7 day supply? ___YES ____ NO

APPLICANT'S CERTIFICATION

I certify that the above statements and attachments are true and correct to the best of my knowledge. I will notify the Department of Social Services (DSS) within 5 days of any changes that occur in my situation. I

understand that I or any member of my household cannot sell merchandise purchased on my behalf through the program unless the local DSS has granted permission to sell. Any benefits received must be used for the

purpose approved. I may file a complaint if I feel I have been discriminated against because of my race, color, national origin, disability, sex, age, political beliefs, religion, sexual orientation, marital or family status.

If I give false information, withhold information, fail to report changes promptly, or obtain assistance for which I am not eligible, I may be breaking the law and could be prosecuted for perjury, larceny and/or fraud. If

I completed, or assisted in completing this application form and aided and abetted the applicant to obtain assistance for which he/she is not eligible, I may be breaking the law and could be prosecuted. I understand the

DSS may use information on this application or that I may be contacted for the purposes of research, evaluation, and analysis to the extent allowed by state and federal law. My signature authorizes the DSS to obtain

any verification to establish my household’s eligibility for assistance or to give information in my case record to other organizations from which I have received or requested assistance. I understand that, by providing

my energy supplier(s) account information, I am authorizing the energy supplier(s) to provide details about my account and energy use to the DSS for the purposes of program evaluation and analysis. If your

application is approved, your Approval Notice will be mailed in late December.

Applicant Signature or Mark and Witness______________________________________________________________________

Date___________________________

Completed on behalf of applicant by: _________________________________________________________________________

Date___________________________

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032-03-0650-07- eng (09/15)