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VIRGINIA DEPARTMENT

OF SOCIAL SERVICES ENERGY ASSISTANCE

10/03 VOLUME IX, CHAPTER C, APPENDIX A, Page 1

COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES Date

VIRGINIA ENERGY ASSISTANCE PROGRAM NOTICE OF APPROVAL FOR FUEL ASSISTANCE This year the Energy Assistance Program is making it easier for some Food Stamp households to receive Fuel Assistance. You have been determined eligible for Fuel Assistance for the winter of 20XX-XX based on the following information. Contact your worker *ONLY* if this information has changed.

Case # ADAPT # Worker # There are people in your home; household members are/are not US citizens (based on Citizenship Code). There is/is NOT a child under age 6 in the home. There is/is NOT a disabled person in the home. There is/is NOT a person age 60 or older in the home. You are (Living Arrangement). Your daytime phone number is (area code + number). Total income for everyone in your house is $ _. Your fuel vendor is (Name), account # is . You heat your home with (Fuel Type) using (Equipment Type). *****IF THE ABOVE INFORMATION IS CORRECT, DO NOT CONTACT YOUR FUEL WORKER. *****

If you withhold information, fail to report changes promptly, or obtain assistance for which you are not eligible you may be breaking the law and could be prosecuted for perjury, larceny and/or fraud. Any benefits received must be used to heat your home. If you feel you have been discriminated against because of race, color, national origin, religion, sex, age, or handicap, you may file a complaint. The Department of Social Services reserves the right to obtain any verification needed to establish your eligibility for assistance or to give information in your case record to other organizations from which you have or may request assistance.

Agency name Address Address City, state, zip

Client Name Address Address City, State, Zip YOU’RE ALREADY APPROVED! NO APPLICATION NEEDED! NO NEED TO CALL SOCIAL SERVICES UNLESS YOUR ADDRESS OR THE INFORMATION ABOVE HAS CHANGED

YOU MUST REPORT CHANGES TO (AGENCY PHONE NUMBER)

NOTICE OF YOUR BENEFIT AMOUNT WILL BE ISSUED IN LATE DECEMBER

BILL PAYMENTS BEGIN IN JANUARY

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