5. LIVING ARRANGEMENTS
Check ( ) the item that best describes the dwelling where you currently live and are applying for assistance. |
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House/Modular Home |
Rooming/Boarding House |
Fraternity or Sorority House |
Cabin |
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Hotel/Motel |
Rehabilitation Center |
Camper |
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Townhouse |
Car/Van/Bus |
Correctional Facility |
5th Wheel |
Apartment/Condominium |
Group Home |
Nursing Home/Residential Care Facility |
RV |
Mobile Home |
Dormitory |
Other Dwelling, Please Specify: ___________________ |
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Do you rent? Yes. If yes, what is your monthly rent? $ ______________________
Do you have a mortgage payment? Yes.
If yes, what is the monthly mortgage payment? $ ____________________; or, do you own your dwelling outright? Yes
Do you pay a lot or space rental amount? Yes. If yes, what is your monthly space rent payment? $ ___________________
What is the name and phone number of your apartment complex or landlord? _____________________________________________
6. SUBSIDIZED HOUSING
Do you live in Section 8, public housing, or do you receive a subsidy to pay your rent? Yes No
7. HEAT/RENT INFORMATION
ARE YOU HAVING AN EMERGENCY WITH YOUR PRIMARY HEATING FUEL RIGHT NOW? Yes
If yes, check type of emergency below and attach a copy of the notice from your energy provider:
Already disconnected. Disconnect Date: ____________________
Received disconnect notice but not yet disconnected. Date disconnect scheduled: ____________________
Propane tank empty or are you out of a bulk fuel such as wood, fuel oil, etc.? Amount needed for minimum delivery: $ ______________
Propane tank at 20% or below. Amount needed for minimum delivery: $ ___________________
Check () the main fuel used to heat (not light) your residence. CHECK ONLY ONE.
Natural Gas Propane Electricity Wood Coal Fuel Oil Kerosene Other: ________________________________
Check () the way in which the heat (not light) is paid for at your residence.
I pay heating costs directly to a utility company or fuel dealer. (If so, attach copy of most recent heating bill).
Name of fuel provider: _____________________________________ Billing account number: _____________________________________
If your electricity is supplied by a different company, please provide:
Electric company name:_________________________________________ Account number: _____________________________________
Name: ______________________________ Address: _________________________________________ Relationship: ________________
______________________________________________________________________________
Heat is included in my rent. (If so, attach a copy of the most recent rent receipt that already shows heat is included.)
Someone other than a member of my household pays my heating costs.
Provide name and address of that person and their relationship to you.
Name: ______________________________ Address: _________________________________________ Relationship: _____________
_________________________________________________________________________________
COMPLETE ALL 4 PAGES AND SIGN PAGE 4. PLEASE RETURN ALL 4 PAGES.