Forms

HEAT Application
This application can be used for all households (Spanish)

HEAT Application for Single Person Household
This application can only be used by an individual living alone (Spanish)

Alimony and/or Child Support Form
Use this form to prove how much alimony or child support has been PAID or RECEIVED. Paid receipts will be deducted from income, and Received will be added as unearned income. (Spanish)

Employer Verification Statement
This form to be completed by the employer if a client has no other record of wages, has recently lost a job, or requires temporary employment verification. (Spanish)

Landlord Statement
This form or a copy of the client’s lease agreement is required if one or both utilities are included in rent. This form must be completed and signed by the landlord. (Spanish)

Medical Release Statement (Proof of disability)
This form may need to be completed by a physician to verify that you have a disability in order to receive a disability credit.  (Spanish)

Moratorium (Shut-off Protection) Form
This form is used by HEAT workers to apply for utility moratorium protection. To be used only between November 15 and March 15. (Spanish)

Self Employment Form
Self employed clients will need this form or a copy of their most recent IRS 1040 to calculate average monthly income. (Spanish)

Tax Information Authorization Form, IRS
This form is required for anyone using a Self Employment Form.

Tribal Agreement for Native Americans
To be signed by individuals whose households may be eligible for tribal LIHEAP assistance.

Weatherization Referral Form
Provide to a client who may need this program  (Spanish)

Household Income Deficit Statement
Required for adults who are claiming zero income or have insufficient income to meet living expenses (Spanish)

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