Vermont Fuel Assistance Eligibility Review printable pdf download

VERMONT FUEL ASSISTANCE ELIGIBILITY REVIEW

Answer all the questions. Write N/A if a question doesn’t apply. Use a separate sheet of paper if you need more room. PLEASE PRINT.

Name

Social Security Number

Mailing Address (Street, PO Box, Town, State, and Zip)

Home Phone (with area code)

Physical Address if Different (Street, House Number, Town, State, and Zip)

Day / Message Phone (with area code)

1. List anyone living in your home. This includes you, your spouse or civil union partner, children, other relatives, roommates,

roomers and boarders, caregivers, companions, and friends. If you need more room, attach another sheet of paper.

Name

Social Security Number

Sex (M/F)

Date of Birth

Relationship

SELF:

SELF

Please answer all of the following questions about the people listed above.

2. Do you rent a room to someone in your home?



Yes

If yes, name of roomer

How much do they pay you for room rent? $

per month.

3. If you are 60 or older or have a disability, does someone live with you to provide care or services? 



Yes

If yes, name

Type of care:  Medically-necessary personal care

 Homemaker/caretaker or companionship services

4. Is anyone listed in Question #1 a full-time college student?



Yes

If yes, name

Where does he/she live while attending classes?

5. Check the box that best describes your living situation.

 I own my home  I rent my home or apartment and pay $

per month  I have a life lease to live in my home

 I rent a room in the home of

and pay $

per month  Other

please describe

6. Who pays the cost of heating your home?

 Heat is included in my rent  I pay the cost directly to my fuel supplier

 My landlord bills me for ALL fuel I use

(NOTE: if landlord bills you, a form will be sent to you for completion by your landlord.)

7. Type of housing?

 Single-family house  Mobile home  Apartment  Other

please describe

8. How many bedrooms do you have (even if not presently used as bedrooms)?

9. What is your MAIN type of fuel used to HEAT your home? (check only one)

 Wood

 Pellets

 Electric*

 Oil

 Bottled or propane gas

 Natural gas

 Kerosene

 Coal

* If electric heat, we may verify this with your electric service provider

10. Is your rent based on your income?

Yes No

If yes, which housing program?  Section 8  Public Housing  Subsidized Housing  Other

11. Who is your fuel supplier?

Name of supplier

Address

Phone number

Name on account

Account number

12. Who is your electricity provider?

Name of provider

Name on account

Account number

Vermont Fuel Assistance Eligibility Review

Related Articles

Related forms

Related Categories