HOME ENERGY ASSISTANCE PROGRAM (HEAP)

List te date of irt o ea ousehold ember. A. MOUNT OF ONTHLY . GROSS. INCOME “gross” income means the amount of oney received eore taes or anyting ese is taken out. you ae ore tan eople in your ousehold, you an rite te inoration on a separate piece o aer . Fir Name L Name Relation o Applicant Date irth . MM/DD/YY . Amoun Monthly Income

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