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LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP) INVOICE (Wood/Coal/Kerosene)

1. DEALER NAME:

DEALER ADDRESS:

DEALER PHONE NO.:

2. DELIVERED:

WOOD AMOUNT: $______________

COAL

$______________

KEROSENE

$______________

3. DELIVERED TO:

(Name/Address)

4. DELIVERY DATE:

5. RECEIVED BY:

(Applicant or Adult Household Member)

6. I certify that the full amount of the above product was delivered as indicated. This invoice is a correct and unpaid bill.

SIGNED:___________________________________________ (Dealer)

INSTRUCTIONS

1. This INVOICE must be completed each time wood, coal, or kerosene is delivered. Dealers are to keep a blank supply of INVOICES on hand.

2. Both the dealer and the applicant (or other household member) must sign before payment can be made.

3. For payment, mail (or deliver) this INVOICE to the Community Action Agency.

4. Mail to:

LIHEAP-117 Reviewed 2024