Town of
Application for Heating Assistance Program Client ID # _________
Date:
__________________________________________________________ Telephone: ______________________________________________________
Name:
_________________________________________________________
Social Security #
________________________________________________________
Address:
_________________________________________________ Birth
date: _______________________________________________________
Members of Household:
Applicant:____________________________Self______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Is the Applicant Currently Employed
______________________________ If yes, Type of Job
_________________________________________________________________
Employer
Address
Reason for Leaving Length
of Employment
Date Job Ended
_______________________________________________________________________________________________________________________________________________
Members of Household who are Employed:
Name Employer____________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Two Most Recent Addresses:
Street
Town
Zip Code
Length of Residence
_____________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
Do you have any minor children who
are NOT living with you? __________ If yes,
Name
Age Who
does this child live with? Address
____________________________________________________________________________________________________________________________________________
Income Expected in the Next 30 Days:
1.
Salary/Wages
$ _________________________
2.
TANF
$ _________________________
3.
SSI
$ _________________________
4.
Social Security
..........$ _________________________
5.
Worker’s Compensation
$ _________________________
6.
Unemployment Compensation
.......... $ _________________________
7.
Pension
$ _________________________
8.
Child Support
$ _________________________
9.
Veteran’s Benefits
$ _________________________
10. Income
from Relatives
...........$ _________________________
11. Other
(Do not list food stamps or Medicaid payments)
..........$ _________________________
TOTAL .......
$ _________________________
Cash on hand today? $_____------____
In bank accounts? Checking $
____-----______ Savings
$_______________
Bank(s):_________________________/______________________________________________________ Acct #
_____________________
Have you sold any assets recently? _______ If yes, type, value and date of sale:
_______________________________________________________________________________________________________________________________________________
List Assets and estimated value:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Have you acquired any assets
recently? ______ If yes, type, value and date of acquisition:
____________________________________________________________________________________________________________________________________________
Have you filed your income tax, ______or applied for tax/rent rebate? ____ How much will your refund (s) be? $_______ When do you expect to receive it?
_______________________________________________________________________________________________________________________________________________
Are you expecting a Worker’s Compensation, law suit, or Social Security settlement? ____________________ If yes, when?
_______________________________________________________________________________________________________________________________________________
Have you received any type of cash settlement in the last 12 months? _________ If yes, when and how much?
__________________________________________________________________________________________________________$____________________________________________
How much was your income in the last 30 days and how did you spend it? List everything you have purchased, and expenses paid, within the last 30 days. YOU ARE EXPECTED TO PROVIDE RECEIPTS FOR INCOME AND EXPENSES PAID
Amount Paid
Office Use
Income
Amount
Received
Expenses
in last 30 days
Only
Salaries/Wages
$__________
Housing $____________
TANF
$__________
Electricity
$____________
Social Security
$__________
Food
$____________
Veteran’s Pension
$__________
Rx Medicine
$____________
Retirement Pension
$__________
Telephone (s) $____________
Unemployment
Comp.
$__________
Cable
$____________
Dividend/Interest
$__________
Internet
$____________
Worker’s Comp.
$__________
Car Expenses $____________
Child Support/Alimony
$__________
Cigarettes/alcohol$____________
SSI
$__________
Diapers
$____________
Income from Relatives
$__________
Credit cards:
$____________
Other
$__________
Other
$____________
TOTAL
$__________
TOTAL
$____________
Please list your________ Vendor ___________________ the Amount of gallons requested ______________________ Type of fuel
_______________________________ ____________ __________________________________________________________
I hereby certify that the facts on this application are true, correct and complete and that I have not knowingly withheld any information regarding my eligibility. I understand that if I willfully give false information I may be disqualified from receiving assistance under the Heating Assistance grant review. I understand that the Administrator is obligated to verify the information I have given and gather other information that may have a bearing on my eligibility and I hereby give my consent.
_________________________________________________________ _________________________________________________________________
Signature of Applicant Signature of Administrator
_________________________________________________________ _________________________________________________________________
Date Date
Under
guidance from the Board of Selectmen, an on site visit may be
required to make the final determination for any grant made to you
and your family.
Funding
for this program is by donation only. At a future date, should you be
able to make a contribution for others to benefit from: Please make
check payable to the Town of