Vermont Fuel Assistance Eligibility Review Page 2
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13. Income Information:
If anyone has income from a job, complete this section.
First Name
Initial
Date paid
Hours
Hourly
Income before
Tips &
Worked
Rate
deductions
Commissions
How often paid?
$
$
$
Weekly Twice a month Every two weeks
$
$
$
Monthly Other
$
$
$
Name and phone number of employer
$
$
$
$
$
$
Date paid
Hours
Hourly
Income before
Tips &
First Name
Initial
Worked
Rate
deductions
Commissions
How often paid?
$
$
$
Weekly Twice a month Every two weeks
$
$
$
Monthly Other
$
$
$
Name and phone number of employer
$
$
$
$
$
$
14. Does anyone have self employment income (e.g., farming, home party sales, logging, rental income)?
Yes No
If yes, YOU MUST send copies of your most recent federal tax return, including all forms and schedules. If you have not filed taxes,
send a statement of business income and expenses for the past three months.
15. Does anyone have unearned income?
Yes
No If yes, fill in the name of the recipient and the GROSS monthly amount
before any deductions such as Medicare premiums, taxes, insurance, child support, or union dues.
Type of Unearned Income Received
Name (s)
Amount Per Month
Social Security
$
Supplemental Security Income (SSI)
$
Veteran’s Benefits
$
Unemployment Compensation
$
Worker’s Compensation
$
Child Support and/or Alimony
$
Interest/Dividends
$
Retirement
$
Adoption Subsidy
$
Rental Income
$
Other
$
I agree to report all changes, including but not limited to: physical or mailing address, members of my household, housing,
heating, and income. If I knowingly give false or misleading information, I understand I can be taken to court for fraud
and if found guilty, may be fined, jailed, or both; may have to pay back any extra benefits received; and be disqualified
from receiving future assistance. If I receive fuel assistance, I agree to accept free weatherization services. I also give ESD
permission to obtain and share any data about my annual energy consumption, cost, usage data, utility charges, payment
history and other account information from my primary and/or secondary heating and energy company or companies. I
authorize the company or companies to provide this information to ESD.
Signature of applicant
Date
Name of person helping fill out this form (printed)
Signature
Date
Phone Number
Relationship or Agency Name
Households who receive fuel assistance agree to accept services from the Weatherization Office to help lower heating costs.
Send completed form to: Economic Services Division, Application & Document Processing Center, 280 State Drive, Waterbury, VT 05671-1500.
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