Application Form For The Low Income Home Energy Assistance Program Page 2

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What is your main heating source?
6
This question is asking about your main heating source, the one that heats your home.
Attach a copy of your last bill. See Instructions on last page. If you do not have a bill yet, but will be paying your own heat, attach a
statement from a utility or fuel dealer stating the type of fuel and that you are accepted as a customer.
Electric
Fuel Oil
Coal
Natural Gas
Kerosene
Propane or Bottled Gas
Blended Fuel
Wood/Other
Are you currently without your main heating source or within 15 days of being without heat?
Yes
No
7
If yes, please explain: ____________________________________________________________________________
Answer question 8 only if you want payment sent to the vendor of your second heating source. A second heating
source is used to run your main heating source in addition to the main fuel (example: electricity to run a gas furnace),
or used if the main heating source is not working.
8
What is your secondary heating source - if any?
Electric
Fuel Oil
Coal
Natural Gas
Kerosene
Propane or Bottled Gas
Blended Fuel
Wood/Other
(Attach a copy of your last bill for your main and second heating sources.)
Are you currently without your secondary heating source or within 15 days of being without heat?
Yes
No
9
If yes, please explain: ____________________________________________________________________________
List the people who live with you at this address. Include all children and adults. Include related roomers. Include all
10
unrelated roomers who share household expenses. Do not include anyone in jail/prison. Do not include the household
member listed in block 1.
See instructions on the last page.
Use the codes below to help provide the details for each individual in your household.
CITIZENSHIP*:
(1) U.S. Citizen, (2) Permanent Alien, (3) Temporary Alien, (4) Refugee, (5) Other-not eligible for benefits
(All non-U.S. citizens must provide proof of citizenship status.)
RACE*: (optional)
(1) Black or African American, (3) American Indian or Alaskan Native:, (4) Asian, (5) White,
(7) Native Hawaiian or other Pacific Islander. List all groups that apply.
ETHNICITY*: (optional)
(1) Non-Hispanic, (2) Hispanic or Latino
MARITAL STATUS*:
(1) Single, (2) Married, (3) Common Law Marriage, (4) Separated, (5) Divorced, (6) Widow/Widower
Social Security
Name
Birthdate
Sex
Race*
Ethnicity*
Marital
Relationship to You
Citizenship*
Number
(Include Last, First, Middle Initial)
(MM/DD/YY)
M/F
Status *
(Optional)
(Optional)
Person 1
Do you receive Cash, MA, or SNAP/Food Stamp benefits?
Yes
No
If yes, may we use the income you have on file for this application?
Yes
No
Social Security
Name
Birthdate
Sex
Race*
Ethnicity*
Marital
Relationship to You
Citizenship*
Number
(Include Last, First, Middle Initial)
(MM/DD/YY)
M/F
Status *
(Optional)
(Optional)
Person 2
Do you receive Cash, MA, or SNAP/Food Stamp benefits?
Yes
No
If yes, may we use the income you have on file for this application?
Yes
No
Social Security
Name
Birthdate
Sex
Race*
Ethnicity*
Marital
Relationship to You
Citizenship*
Number
(Include Last, First, Middle Initial)
(MM/DD/YY)
M/F
Status *
(Optional)
(Optional)
Person 3
Do you receive Cash, MA, or SNAP/Food Stamp benefits?
Yes
No
If yes, may we use the income you have on file for this application?
Yes
No
Social Security
Name
Birthdate
Sex
Race*
Ethnicity*
Marital
Relationship to You
Citizenship*
Number
(Include Last, First, Middle Initial)
(MM/DD/YY)
M/F
Status *
(Optional)
(Optional)
Person 4
Do you receive Cash, MA, or SNAP/Food Stamp benefits?
Yes
No
If yes, may we use the income you have on file for this application?
Yes
No
If you have additional people in your house, please provide their information on a separate piece of paper and send it along with this application.
If you answered yes for everyone in question 10, skip to question 12. If you answered no for
anyone in question 10, complete question 11 for that person.
Apply online at

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