Transcription of HOME ENERGY ASSISTANCE PROGRAM APPLICATION
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HOME ENERGY ASSISTANCE PROGRAM APPLICATION
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 If you are blind or seriously visually impaired, would you like to receive written 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.
ldss-3421 (rev. 5/17) home energy assistance program application 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.
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