Financial Assistance Form

HOME ENERGY ASSISTANCE PROGRAM (HEAP)
FINANCIAL ASSISTANCE STATEMENT
Applicant Name*
Application #*
To Be Completed By the Person Giving the Assistance
(Printed name of person GIVING assistance)*
I {printedName} certify under the penalties of perjury that

the following is a true and complete account of the financial assistance I gave

{applicantName}
I give them:*
Per

WeekMonth
This assistance began:

MonthDayYear
Date
And will continue until

MonthDayYear
Date
If the assistance is not continuous, the amount (s) given from
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Total Amount Given:
My relationship to the Applicant is
My address is
My telephone number is
Signature of person giving assistance
Date

MonthDayYear
Date
Should be Empty:

FINANCIAL ASSISTANCE STATEMENT