Form 032-03-0651-08-Eng - Crisis Assistance Application printable pdf download

Commonwealth of Virginia - Department of Social Services

AGENCY USE ONLY:

Locality/FIPS____________________

Case #______________________________

ADAPT #_________________________

Date Application Received____________________

Worker #________________________

CRISIS ASSISTANCE APPLICATION

Applications are accepted from November 1 through March 15

PLEASE ANSWER ALL QUESTIONS COMPLETELY

Part I

In what city or county do you live?

____________________________

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 crisis need? (Check all that apply.)

___A. Heating equipment repair

___B. Purchase of Heating Equipment

___D. Payment of security deposit

___D. Deposit for LP Gas Tank

___F. Purchase of portable space heater

___G. Emergency Shelter

___T. Supplemental Equipment or Equipment Maintenance

Crisis Assistance – Emergency Fuel is available effective January 1

____ W. Purchase of Primary Home Heating Fuel

____ X. Payment of primary heat utility bill

If you are having an energy emergency right now, check the type of emergency 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? _____________

□ Coal or Wood

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

Less than 7 day supply? ___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 subsidized housing/Section 8/ HUD & 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/cooling.

F. I live in subsidized housing/ Section 8/ HUD and occasionally pay

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

excess usage charges.

one room

3. 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

MONTHLY