Page 117

VIRGINIA DEPARTMENT OF SOCIAL SERVICES ENERGY ASSISTANCE

06/11 VOLUME IX, CHAPTER G, APPENDIX B, PAGE 1

CRISIS/COOLING CREDIT AUTHORIZATION

XXXXXXXXXX XXXXXXXXXXXX XXXXXXXXX, XX 12345

XXXXXXXXXXXXXXX 111 XXXXXXXXXXX XXXXXXXXXX, XX 54321

COMMONWEALTH OF VIRGINIA DATE: ENERGY ASSISTANCE PROGRAM CASE #: CASE NAME: ADDRESS: Worker: Account #: Account Name: Phone:

CRISIS/COOLING CREDIT AUTHORIZATION

Please provide merchandise or services as follows:

INSTRUCTIONS TO VENDOR: 1) Do not exceed the maximum authorization to right 2) Enter actual cost and date. Enter kerosene gallons. 3) Attach a copy of the itemized bill as verification. 4) Return signed original to the local agency named above.

MAXIMUM AUTHORIZATION $ 500.00 (Do Not Exceed this amount)

SERVICE/MERCHANDISE COST$ SERVICE/DELIVERY DATE –

# WARRANTY YEARS ON MERCHANDISE

# KEROSENE GALLONS DELIVERED DYED CLEAR

I CERTIFY THAT THIS BILL IS CORRECT AND THAT THE MERCHANDISE OR SERVICE HAS BEEN PROVIDED AS DESCRIBED.

VENDOR _ DATE CUSTOMER

DATE

TRANSMITTAL # 11-1