LDSS5081Rev 517HOME ENERGY ASSISTANCE PROGRAM HEAPHEATING EQUIPMENT CLEAN ANDTUNE REQUEST FOR BENEFITIApplicant InformationDate StampSocial Security NumberDate ofBirthNameHeating SourceFuel OilElect ID: 872163
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1 LDSS - 5081 (Rev. 5 /1 7 ) Case Num
LDSS - 5081 (Rev. 5 /1 7 ) Case Number: ________________________ HOME ENERGY ASSISTANCE PRO G RAM (HEAP) HEATING EQUIPMENT CLEAN AND TUNE REQUEST FOR BENEFIT I. Applicant Information Date Stamp: Social Security Number: Date of Birth: Name: Heating Source Fuel Oil Electric Kerosene Natural Gas Propane/Bottled Gas Wood/Wood Pellets Coal or Corn Address: Telephone Number: Are you a: Homeowner Renter Do y ou h ave a p rogrammable t hermostat? Yes No If no, would you like one installed? Yes No Do you have a working carbon monoxide detector less than 5 years old ? Yes No - If no , one will be installed. II. Fuel Vendor Name of Vendor: Address of Vendor: Do y ou h ave a s ervice c ontract w ith t his v endor? Yes No Does v endor p rovide c lean and t une s ervice: Yes No Do Not Know Date of l ast h eating e quipment c lean and t une/ c himney c leaning : Name of v endor w ho p rovided c lean and t une s ervice if d ifferent t han a bove: III. Applicant Signature Signature: Date: AGENCY USE ONLY Denied Reason: Approved Date: Vendor Name: Vendor Number: Worker’s Signature: Supervisor Signature : Comments: