Page 6 - Full_Application_for_print
P. 6
Assistance Application
Page 3
Utility Service Information
How is the home heated? Space Heater Window Unit Central Heat Wood
Window Unit
How is the home cooled? Box fans Ceiling fans Central Air
In rent payment
List any other devices used to heat or cool the home:
How are the heating/cooling bills paid? To Utility Company To Landlord
Electric Service: Heat Cool Cook Heat Water
Utility Company Account Number
Natural Gas Service: Heat Cook Heat Water
Utility Company Account Number
LP Gas Service: Heat Cook Heat Water
Utility Company Account Number
Water Service Account Number
Utility Company
Other Energy Service: Heat Cool Cook Heat Water
Utility Company Account Number
Certification
1. The information provided is true and correct to the best of my knowledge and belief.
2. My household income has been annualized at the time of application according to pre-established procedures.
3. I understand I may appeal a denial of eligibility, and amount of assistance received, or a delay in service delivery.
4. I authorize the Texas Department of Housing and Community Affairs (TDHCA) and its contracted agencies to
solicit or verify information on my utility and/or fuel bills, both past and future to the extent the information is used
only to provide data relevant to my application for assistance.
5. I am aware that I am subject to prosecution for providing false, misleading, or fraudulent information.
Applicant Signature Date
For Office Use ONLY
Eligible? Yes No If no, has applicant requested an appeal? Yes No
Income denial? Yes No If yes, what is the annualized income?
Is there a priority member in the household? Elderly Elderly/Disabled Documented crisis
Disabled Child Under 6 Cutoff notice
Recommended Utility Assistance Component: HCC UA Other
Caseworker Signature Date
Page 6 Version 9.17
