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pg. 120 Appendix H – LIHEAP Energy Assistance Refund

FROM

Supplier name: __________________________________________ Supplier number: __________________________________________ Staff to follow up with (if questions): __________________________________________

PLEASE MAIL FUNDS AND THIS FORM TO:

Missouri Department of Social Services FSD, Low Income Home Energy Assistance Program P.O. Box 2320 Jefferson City, Missouri 65102-2320

Make checks payable to Missouri Department of Social Services If questions: FSD.LIHEAP@dss.mo.gov

THIS CHECK REPRESENTS A REFUND FOR THE FOLLOWING CUSTOMER(S):

Name: ______________________________________________ Social security number: ________________________________ Account number: ______________________________________ Reason for refund: _______________________________________________________

Name: ______________________________________________ Social security number: ________________________________ Account number: ______________________________________ Reason for refund: ________________________________________________________

Name: ______________________________________________ Social security number: ________________________________ Account number: ______________________________________ Reason for refund: ________________________________________________________

Name: ______________________________________________ Social security number: ________________________________ Account number: ______________________________________ Reason for refund: ________________________________________________________

Name: ______________________________________________ Social security number: ________________________________ Account number: ______________________________________ Reason for refund: ________________________________________________________