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LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM VENDOR REFUND FORM

Agency Name:

______________________________________________ Date:

_______________________

Beneficiary’s Name: ______________________________________________ Beneficiary’s System ID: ___________________________

Vendor:

______________________________________________ Date Benefit Issued: _______________________ Date Refund Returned: _______________________

Amount of Refund:

$______________________

Method of Refund:

Check

Other ____________________________

Program (check one): Heating

Cooling

Crisis Heating Crisis Cooling