HEAP Utility Assistance Appointment Request
If you have already been serviced for the current PROGRAM YEAR, your request will be denied. Please provide complete and accurate information into the form below. Incomplete requests will not be considered.
Name
Email address
(to which our reply will be sent)
Phone
What is your current address?
Please indicate if you would like to request an appointment for HEAP Assistance, or if you live over a 50 mile radius from our office, you may request to either email or mail in your application, if preferred. With either option, you will still need to fill out the entire form below.
HEAP Utility Appointment Request
I live outside of the 50-mile radius and would like to email or mail in my application (address will be verified)
What is the last 4 digits of your Social Security number?
**Notice** If the applicant's name is not on the bill you are seeking assistance with, the account holder is expected to sign the consent form (provided by the agency) before assistance is provided to the applicant.
Comments
Please provide us with your special circumstance or pertinent information to your request.
I certify that all the above information is true and correct to the best of my knowledge. I also understand I will need to provide back up documentation for all the information provided above in addition to providing all the required documents listed on the "Documents to Bring to Your Appointment" button below.
I accept and certify
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Submit the HEAP Assistance Request Form