Form 032-03-0651-08-Eng - Crisis Assistance Application (Page 2 of 2) in pdf

4. Are all people in your household United States citizens? ___YES ___NO

If NO, who is not a citizen? _______________________________________________________________

5. Is anyone in your household disabled?

___YES ___NO

If YES, who is disabled? _________________________________________________________________

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 a payment from the Division of Child Support Enforcement? ___YES ___NO

How much? ________ Who pays the child support?_________________________________

8. Did you or any household member receive Fuel, Crisis or Cooling Assistance in the past 12 months? ___YES ___NO If yes, case name____________________________________________

9. Does any household member receive SNAP benefits (formerly Food Stamps)? ___YES ___NO If yes, case name_____________________________________________________________

10. Does any household member receive Medicaid? ___YES ___NO

If yes, case name___________________________________________________________________________________

11. Is Medicaid Home & Community-Based Care received? ___YES ___NO

If yes, by whom? ____________________________________

Patient pay amount is $__________

12. Does anyone pay for Medicare, Part B___ or D ___ insurance? ___YES ___NO

If yes, who?____________________________________

How much? $_________________

13. Circle the type of equipment you use as the primary/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. Cookstove

K. None

L. Unknown

14. Is your heating equipment working? ___YES ___NO

Describe any current problem with your heating equipment _____________________________________________________

15. If your heating equipment is not working, do you have another heat source? ____YES____NO

If yes, what? ____Fireplace ____Wood Stove ____Portable Space Heater

____Other

16. Who owns or is responsible for purchase or repairs of your heating equipment? _________________________________________________________________________________________

17. 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

18. Name and address of the company used for home heating: __________________________________________________________________________________________________________

Verification from the utility company is needed if you heat with electricity or natural gas. A Crisis Assistance benefit can only be paid if you owe a balance that will lead to disconnection of your service

or if your PrePay electric service account balance is less than $25. Attach a copy of your current electric bill, gas bill, or proof that you have a balance of $25 or less in your Prepay electric service

account. 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

19. Do you have a family member or friend who can provide you with temporary shelter? ___YES ____NO

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

20. If electricity is not the fuel you use to heat your home, what is the name of the company used for your electric service?___________________________________________________________

Account Name_______________________________________________________________

Account Number_______________________________________________________

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.

Applicant Signature or Mark and Witness____________________________________________________________________

Date___________________________

Completed on behalf of applicant by: ______________________________________________________________________

Date___________________________

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032-03-0651-08-eng (09/15)