Fuel Assistance

Your Name (required)

Your Date of Birth (required)

Your Email (required)

Your Telephone (required)

Your Address (required)

Your Gender (required)
Select an OptionMaleFemale

Your Race & Ethnicity (required)

Number of Household Members (required)

Your Income (required)

Name of Provider (required)

Account Number (optional)

Amount Due (optional)

If oil or propane, can your tank hold at least 100 gallons?
Select an OptionYESNO

Veteran
Select an OptionYESNO

Medicare
Select an OptionYESNO

Medicaid
Select an OptionYESNO

Do you have any concerns about Medicare or Medicaid coverage?
Select an OptionYESNO

Type of Assistance Needed
Electric BillWoodPropaneCoalHeating Oil #1Heating Oil #2Heat Pump Repair

Certification
I certify that the information I have provided for my eligibility determination is correct. I understand that making a false or misleading statement or intentionally misrepresenting, concealing, or withholding facts may result in my ineligibility in the program presently and in the future.

Comments or Concerns

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