GET HELP

SERVICE ADDRESS – Address where applicant lives (this cannot be a P.O. Box)

FULL NAME: Full name is First Name, Last Name.
RELATIONSHIP TO THE APPLICANT: For example: husband, daughter, friend, aunt, grandfather, etc.
DATE OF BIRTH: List the date of birth of each household member.
AMOUNT OF MONTHLY GROSS INCOME: “gross” income means the amount of money received before taxes or anything else is taken out. If you have more than 7 people in your household, you can write the information on a separate piece of paper.

Check all that apply for each type of energy source for any home energy costs.
NOTE: The questions below are MANDATORY and require a response.
Required: Attach copies of all most recent energy bills and/or receipts. A copy of an electric bill must be included.

ELECTRIC SERVICE:

NATURAL GAS SERVICE:

WOOD, PROPANE or FUEL OIL SERVICE (WPO):

The information on this application will be used to determine and verify my eligibility for assistance. My signature gives consent for this information to be shared with my utility company(ies), and for my utility company(ies) to share my account information with LET THERE BE LIGHT NONPROFIT (LTBL) for the purpose of providing services to me and to coordinate, improve and reduce the costs of services under these programs. I further authorize my utility company(ies) to provide my energy consumption data to LTBL to the extent necessary for LTBL to comply with the program reporting requirements of the federal government. I understand that this consent shall remain in effect for three years from the date signed unless otherwise revoked by me in writing. I understand that if my application for LTBL assistance or services may be denied. I declare, under penalty of perjury, that the information on this application is true, correct, and that the funds received will be used solely for the purpose of paying myenergy costs.

AGENCY NAME: LET THERE BE LIGHT NONPROFIT (LTBL). PURPOSE: The information you provide will be used to decide if you are eligible for a LTBL payment services. GIVING INFORMATION: This program is voluntary. If you choose to apply for assistance, you must give all required information. OTHER INFORMATION: LTBL uses statistical definitions from the annual update of the Department of Health and Human Services' State Median Income, Federal Income Poverty Guidelines, to determine program eligibility. During application processing, LTBL may need to ask you for more information to decide your eligibility for assistance. ACCESS: LTBL will keep your completed application and other information, if used, to determine your eligibility. You have the right to access all records holding information about you. LTBL does not discriminate in the provision of services on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, or sexual orientation.

Please forward completed application to Fred White (fredw@ltblnonprofit.org) or contact us at 954-629-3164