Attach extra pages if you need to include additional members. List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for each member.
Home Heating Credit (HHC): Have you applied for or received the HHC (Energy Draft) in the last 6 months?
Have you received energy assistance from another agency or through a provider- sponsored program since October 1?
*Electric heat sources include solar panels, boilers, radiators, or baseboard heating but DO NOT include space heaters
Please sign below after reading the following information, otherwise this application will be considered incomplete
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