Power of Warmth

Power of Warmth

This is for Heaters ONLY
Application Entered by:*
Volunteer's Name or Initials
Today's Date*

MonthDayYear
Today's Date

MonthDayYear
Date
Site

North Center (Main)Other
MLGW Account Number*
Last 4 numbers of SSN*
Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
CONTACT INFORMATION

Please enter a working cell phone number
Home Phone
Cell Phone*
Work Phone
E-mail
example@example.com
DEMOGRAPHIC INFORMATION
Source of Income*
Gender*
Race*
Primary Language*
Housing Status*
Marital Status*
Current Employment Status*
How many years have you been in the home?*
Education Level*
Are you a military veteran?*
Number of children under age 6 in the home:*
Approximate Monthly Household Income*

Less than $500$500 to $999$1,000 to $1,999$2,000 to $2,999$3,000 to $3,999$4,000 or more
Income Amount*
Total Number of Residents:*
Is anyone in the home disabled?*

YesNo
Are you the Head of Household:*

YesNo

Additional Residence

Additional Information
Which item would you like?*
Choose only one
What type of heat system do you have in your home now? (check all that apply)*

Central heat (gas/electric)Wall heater(s) (gas/electric)Floor/FurnaceSpace heater(s)I don't have a heating system
Why do you need an emergency heater? Check all that apply*

Current system has stopped workingCurrent system is not giving enough heatThe gas or electric service is not working right or has been cut off
Why do you need an electric blanket heater? Check all that apply*

Current system has stopped workingCurrent system is not giving enough heatThe gas or electric service is not working right or has been cut off
Uploads

Please upload your proof of income and ID, individually, in the areas below.
Upload Proof of Income*

Browse Files

Cancelof
Upload ID Here*

Browse Files

Cancelof
Should be Empty:

Additional Information