Home Energy Assistance Target (HEAT) Program

HEAT 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)

Crisis Budget Form. This budget form is to be used for clients in crisis and for clients that are high energy users. (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)

Lost Check Replacement Form. Use this form if a client has lost a check and needs to have it replaced.

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.

Utility Verification Stamp.

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)