Fuel Bill in Name of Person Outside the Household

COMMUNITY ACTION PROGRAMS INTER CITY, INC.

100 Everett Avenue, Unit 14

Chelsea, Massachusetts 02150

Tel: (617) 884-6130 Fax: (617) 889-8145

HOME ENERGY ASSISTANCE PROGRAM (HEAP)

Utility/Deliverable Fuel Bill in Name of Person Outside the Household

This form is to be completed by the LIHEAP Applicant when there is no other proof of address for the person listed on the utility/deliverable fuel bill.
Application #
Applicant Name
Address
City, State, Zip
Utility
Utility Type:
Utility Company Name
Utility Account #
Utility Customer Name
Deliverable:
Customer Address
Deliverable Company Name
Deliverable Customer Name
Deliverable Customer Address
Please explain the circumstances that led the Applicant to use the Customer's name utility/deliverable bill.
I acknowledge that I was granted explicit permission from the person listed under the Utility and/or the Deliverable "Customer Name" above to use his/her name on the related bill.
Applicant Signature

Clear
Date

MonthDayYear
Date
Please return the completed form to CAPIC.
Should be Empty:

Utility