Low Income Home Energy Assistance Application
Date
*
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
-
Area Code
Phone Number
Birth-date
-
Month
-
Day
Year
Date
Tribal Affiliation
*
Tribal Verification
*
Browse Files
Cancel
of
Additional household members:
Name
Date of Birth
Member1
Member2
Member3
Member4
Member5
Member6
Member7
Any household members 55 or older?
Yes
No
Any household members handicapped or disabled?
Yes
No
Any household members 6 or younger?
Yes
No
Check the type of energy used in the home
Electric
Propane/Gas
Wood
Do you have a SHUT OFF NOTICE? If Yes please FAX notice to (530)245-4580
Yes
No
Attach Copy of Bill
Browse Files
Cancel
of
Income Verification
*
Browse Files
Cancel
of
Total Household Income(in dollars). Please FAX income verification to (530)-245-4580
*
For example 1500
Please verify that you are human
*
Submit
Should be Empty: