Heating Fuel Assistance Eligibility
Self-Declaration

Applicant Information

Full Name Mailing Address City State ZIP Code Phone Number

Household Information

Number of People in Household Total Monthly Household Income Income Sources (check all that apply):

Heating Fuel Information

Type of Heating Fuel Used Fuel Supplier Name Fuel Account Number

I certify that the information provided above is true and complete to the best of my knowledge. I understand that providing false information may result in denial of assistance or other penalties as allowed by law.

Applicant's Signature

Date

Heating Fuel Assistance EligibilitySelf-Declaration

Applicant Information

Household Information

Heating Fuel Information

Heating Fuel Assistance Eligibility
Self-Declaration