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VIRGINIA DEPARTMENT

OF SOCIAL SERVICES ENERGY ASSISTANCE

10/17 VOLUME X, CHAPTER A, APPENDIX A, PAGE 1

The forms utilized in the EAP are identified below. Forms can be accessed through SPARK at: http://spark.dss.virginia.gov/divisions/bp/ea/ or at http://www.localagency.dss.state.va.us/divisions/dgs/warehouse.cgi. Instructions accompany forms

FORM NAME

FORM NUMBER Affidavit on Check Endorsement

032-06-0118-09-eng (07/14) Affidavit on Check Endorsement (Spanish)

032-06-0118-04-spa (02/04) Appeal to State Department of Social Services

032-03-0024-09-chi (07/04) Appeal to State Department of Social Services

032-03-0024-09-far (07/04) Appeal to State Department of Social Services

032-03-0024-09-ara (07/04) Appeal to State Department of Social Services

032-03-0024-10-eng (01/10) Appeal to State Department of Social Services (Spanish) 032-03-0024-09-spa (10/09) Benefit Programs Brochure

B032-01-0002-20-eng (06/17) Checklist of Needed Verifications

032-03-0814-10-eng (09/11) Checklist of Needed Verifications (Spanish)

032-03-0814-10-spa (09/11) Confidentiality Form

032-01-0040-03-eng (09/04) Cooling Assistance Application

032-03-0657-14-eng (07/17) Cooling Assistance Application (Spanish)

032-03-0657-09-spa (07/17) Correction of Payment (COPE)

032-03-0201-09-eng (10/08) Crisis Assistance Application

032-03-0651-11-eng (10/17) Crisis Assistance Application (Spanish)

032-03-0651-06-spa (10/17) Energy Assistance Program Information Sheet

032-03-0661-15-eng (10/17) Energy Assistance Program Information Sheet (Spanish) 032-03-0661-15-eng (10/17)

TRANSMITTAL #17-1