Please notice that there is a number next to every question or field in this application. These numbers will serve as a guide for filling out this application.
01. Last Name – Print the last name of the Applicant.
02. First name – Print the first name of the Applicant.
03. Middle Initial (MI) – Print the middle initial of the Applicant.
04. Street Address – Print the full street number and name of your primary residence.
05. City – Print the name of the municipality where the primary residence of your household (family) is located.
06. State – Print the name of the state where the primary residence of the household (family) is located.
07. Zip Code – Enter zip code of household’s (family) primary residence.
08. Telephone number – Enter household’s (family) primary telephone number (include area code).
09. Housing Type – Indicate in what type of housing unit you reside.
10. Mailing Address – Enter your full mailing address if different from primary residence.
11. List of all household members – In this section, please write/print the names and gender of all household members residing in the unit, starting with the head of household; dates of birth for every member of the household; relationship to the head of the household; social security numbers for all the members of the household and declaration of US citizenship. Please also indicate household members who are disabled.
12. What are you applying for? – Check for which of the following programs you are applying for: Heating/USF, Cooling or Weatherization.
13. In this section answer every question to the best of your knowledge.
14. Primary Heating Fuel Type – Please indicate your primary heating fuel (example: if you pay for natural gas to heat your house, but have to use an electric heater to heat any specific room of your unit, your primary heating fuel type will be natural gas).
15. Heating Fuel Supplier Name – Print the name of the company that supplies your heating fuel (Example: PSEG Co., Scott Oil Co. etc.).
16. Natural Gas Account Number – Enter your gas utility account number. You can find this number on your gas and electric bill.
17. Natural Gas Company Name – Please indicate the name of the company that supplies your natural gas.
18. Electric Account Number – Enter your electric account number if different from your gas account. You can find this number on your electric bill.
19. Electric Company Name – Indicate the name of the company that supplies your electricity.
20. Authorized Representative – Print the Name and Address of the person who is submitting this application on your behalf. This person’s name will appear on all
Home Energy Assistance benefit checks that you will receive. If you are completing your own application leave this space blank.
21. Main Language spoken in your household – Enter main language used in your household (English, Spanish, French, etc.).
22. Household Income – Indicate the income and pay cycle of all members of your household (age 18 and over) using the list of possible income sources found on the right side of income block.
23. Weatherization – Check ‘yes’ or ‘no’ to indicate if your unit has been weatherized. If ‘yes’ enter the month and the year (if known).
24. Applicant Certification – Please read, sign and date Applicant Certification (You must sign this certification otherwise your application will not be processed).
25. Race – Please indicate your race (optional).