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Fuel and Electric Assistance Program Application

Page 1 of 3 Office Use Only Received Date Stamp Applications for Fuel Assistance accepted until 4/30/27. Electric Assistance applications accepted year-round.

Applicant Name _________________________________ Total Number of Household Members __________ Street Address _________________________________ City ___________________ Zip Code _________ Mailing Address _________________________________ City ___________________ Zip Code _________ Email Address _________________________________ Phone Number(s) _________________________ Preferred Language ____________________________ Would you be interested in Weatherization Assistance? ☐ Yes ☐ No

Housing Type ☐ Apartment ☐ Condo ☐ Duplex ☐ Mobile Home ☐ Single Family ☐ Room Do you ☐ Own or ☐ Rent Monthly Rent or Mortgage Amount $___________ /mo Lot rent or HOA/Condo Fee Monthly Amount $___________ /mo My rent is subsidized - I pay $___ /mo Renters – check all that apply ☐ Heat Included ☐ Electric Included ☐ No utilities included

# of Rooms in Home: Bedrooms ___ Bathrooms ___ Kitchen ___ Living Rm ___ Dining Rm ___ ** Do not include closets/pantries, hallways, unheated attics/basements/porches, etc**

Electric Company _______________________________ Account Number ___________________________ Customer Name on Electric Bill ______________________________________________________________

Do you have a disconnect notice for your electric or gas service? ☐ Yes ☐ No If heat is included with rent, are you facing eviction?

☐ Yes ☐ No If yes to either of these two questions, please share date of disconnect/eviction _________ and copy of notice.

Primary Heat Type ☐ Oil ☐ Kerosene ☐ Propane ☐ Natural Gas ☐ Electric Heat ☐ Wood ☐ Pellets ☐ Included in Rent Secondary Heat? ☐ No ☐ Yes (Type): Check if true: ☐ My fuel tank is shared

Heat/Fuel Provider _____________________________ Account Number __________________________

Customer Name on Heat/Fuel Account _____________________________________________________

How much fuel do you have currently? _____________ (i.e. 2/3 tank of oil, 70% tank propane, 3 cords wood, etc) Housing Electric Provider Don’t include space heaters Heat/Fuel/Wood Provider