Application for Team Heat

Application for Team Heat

Team Heat is a financial assistance MATCHING program (up to $200) to help pay your heating bill during the winter months. This program is available for families in St. Joseph County, IN with income at or below 250% of the poverty level. Limited funds are available. To receive funds you MUST have made a payment toward your bill within the month.
Personal Information

Please fill out this section completely.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Last 4 of SSN*
Number of Adults in your household*
Number of children in your household*
aged 17 and younger
Choose the best description of your household*

Single PersonSingle Parent - FemaleSingle Parent - Male2 Parent HomeNon-Related Adults with ChildrenMultigenerational HomePrefer not to sayOther
Choose the best description of your current housing situation*

OwnRentOther Permanent HousingHomelessLand ContractOther
Ethnicity*

Not Hispanic or LatinoHispanic or LatinoPrefer not to sayOther
Race*

American Indian/ Alaska NativeNative Hawaiian/Pacific IslanderAsianWhiteBlack/AfricanUnkownOther
Have you ever received any assistance from St. Vincent de Paul Society before? (Including food, clothing, furniture or financial help)*

YesNo
For which utility service are you applying this month?*

WaterElectricGas
What is your current employment status?*

Employed full-timeEmployed part-timeUnemployed and looking for workUnemployed but not looking for workStudentActive MilitaryRetiredUnable to work/Disabled
Have you served in the military?*

YesNo
What is your annual household income?*

0-$14,999$15,000-$24,999$25,000-$34,999$35,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$149,999
Have you received financial assistance from St. Vincent de Paul in the past month with Team Heat program*

YesNo
Have you received any type of income in the last 30 days? (Income includes money from jobs, Social Security, Disability, TANF, Child Support, and Alimony.)*

YesNo
Proof of income (pay stubs, disability benefits, Snap benefits)*

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I am attesting that I have not received any federal benefits, employment or unemployment compensation in the last 30 days as of the date of this document.

I understand by clicking Agree below, that I am responsible for reporting true and acccurate information for the purpose of receiving financial aid benefits. In the case that this information is inaccurate, I understand I may be disqualified from assistance today or in the future.
I agree.
Photo ID of person in the bill*

Pictures and PDF files are allowed. Please make sure all pictures are legible. Pictures that are not in focus will result in denial of the application.
Cancelof
Proof of address*

We can only serve people in St. Joseph County. Please make sure all pictures are legible. Pictures that are not in focus will result in denial of the application.
Cancelof
Utility bill you want help paying. This MUST be a current bill, and you MUST have made a payment toward the bill to receive matching funds. The bill must include name of utility company, your name, address and account number)*

It has to be in your name and of the current location you live at. Please make sure all pictures are legible. Pictures that are not in focus will result in denial of the application.
Cancelof
Receipt for most recent paid utility bills (even if only partial payment was made). You MUST have made a payment to be eligible for the match. Must include name of utility company, your name, address and account number*

Cancelof
I am attending a Financial Literacy Class
Consents for services
I agree to be contacted by St. Vincent de Paul Society staff or volunteers regarding the assistance I received. I also consent to the use of my name for reporting and fundraising purposes only.
I understand that the St. Vincent de Paul Society of St. Joseph County, Inc. (SVDP), may need to obtain and/or share information about me to establish my eligibility for services such as client choice pantry, home food delivery, food and clothing vouchers, rent and utility assistance, and any other SVDP program for which I apply. I also understand that SVDP may obtain and/or share information about me through written, oral, and electronic communication.

By submitting this form:
- I authorize SVDP to obtain information about me from other agencies, organizations, and individuals for the limited purpose of making decisions about my eligibility for and participation in one or more SVDP programs.
- I authorize SVDP to share information about me from other agencies, organizations, and individuals for the limited purpose of making decisions about my eligibility for and participation in one or more SVDP programs.
- I understand that my authorization will remain effective from the date I sign below until I withdraw this authorization in writing.
- I understand that I may withdraw this authorization at any time by delivering a written notice to the Executive Director of SVDP, and that my withdrawal will be effective when SVDP receives it.
- I understand that SVDP will handle my personal information in compliance with all applicable laws.
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Application for Team Heat

Personal Information

Consents for services