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Get NY LDSS-3421 2020-2024

LDSS-3421 Rev. 5/17 HOME ENERGY ASSISTANCE PROGRAM APPLICATION If you are blind or seriously visually impaired and need this application in an alternative format you may request one from your social services district. For additional information regarding the types of formats available and how you can request an application in an alternative format see the attached instructions or visit www. otda*ny. gov* notices in an alternative format Yes No If Yes check the type of format you would like Large Print Data CD Audio CD Braille if you assert that none of the other alternative formats will be equally effective for you. If you require another accommodation please contact your social services district. PLEASE READ THE INSTRUCTIONS ATTACHED TO THE BACK OF THE APPLICATION* ANSWER ALL QUESTIONS* DO NOT WRITE IN THE SHADED AREAS* PLEASE PRINT CLEARLY AND SIGN THE FORM ON PAGE 5. COMPLETE THE WHITE BOXES BELOW IN BLUE OR BLACK INK. AGENCY USE ONLY CONTACT THE AGENCY ABOVE IF YOU NEED HELP DSS OFA/ALTERNATE CERTIFIER DATE RECEIVED APPLICATION DATE OFFICE UNIT ID WORKER ID CASE TYPE CASE NUMBER REGISTRY NUMBER REGULAR EMERGENCY CASE NAME HEATING EQPT CLEAN TUNE VERS* COOLING OTHER SECTION 1 HOUSEHOLD COMPOSITION APPLICANT INFORMATION FIRST NAME LAST NAME MI OTHER NAME OTHER NAMES BY WHICH I HAVE BEEN KNOWN ARE CURRENT STREET ADDRESS STATE APT. ZIP CODE CITY LENGTH OF TIME AT THIS ADDRESS COUNTY DAYTIME PHONE NUMBER WHERE I CAN BE REACHED Area Code Phone No* BEST TIME TO CALL YEARS MONTHS IF AN INTERVIEW IS NEEDED I WOULD LIKE A Phone Interview In Person Interview MY MAILING ADDRESS IF DIFFERENT FROM ABOVE IS ADDRESS HAVE YOU EVER APPLIED FOR HEAP YES NO IF YES ENTER DATE OF MOST RECENT APPLICATION STATE ZIP CODE LIST EVERYONE INCLUDING YOURSELF WHO CURRENTLY LIVES IN THE SAME HOUSE If no one else write NONE UNDER YOUR NAME CD LN DATE OF SEX BIRTH MO. DAY YR* M/F RELATION TO ME SOCIAL SECURITY NUMBER SELF CITIZEN / NATIONAL OR QUALIFIED ALIEN BLIND DISABLED YES NO YES NO If there are more members in your household please attach a separate sheet of paper. Total Number in Household DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET OR HAVE RECENTLY APPLIED FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM SNAP If yes who CASE NUMBER PAGE 2 SECTION 2 HOUSING CHECK ONE BOX ONLY HOMEOWNER Single Family House or Mobile Home Multi-Family House List Number of Units Co-op/Condo Owner Life Estate/Use OTHER I live with someone else and share expenses I pay for a room I pay room and board Permanent hotel/motel Other living situation MY MONTHLY RENT OR MORTGAGE PAYMENT IS RENTER Private House Apartment or Mobile Home SUBSIDIZED RENT Private Subsidized Housing Public Housing Project or Senior Housing Public Subsidized Housing Do you receive a HUD utility allowance Yes If yes how much No NONE IF APPLICABLE THE NAME OF THE APARTMENT BUILDING OR HOUSING PROJECT I LIVE IN IS SECTION 3 HEAT AND UTILITY INFORMATION 1. DO YOU PAY SEPARATELY FOR HEAT Yes- Complete information below My main source of heat is Natural Gas Fuel Oil PSC Electric Wood/Wood Pellets Kerosene Propane or Bottle Gas My fuel tank is Individual Tank Metered Tank Is the heating bill in your name If No name on the bill Are you directly responsible to pay the bill Coal or Corn Municipal Electric Relationship to you Your heating account number is Please check if this is a landlord s account number STREET ADDRESS CITY/TOWN If yes is the electric bill in your name YES Complete information below Is electric necessary to run the furnace Is electricity necessary to operate the thermostat in your apartment 3.

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