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Circle one: House Mobile Home Apartment Duplex Triplex Townhouse Other Do you own your home? If yes, monthly mortgage amount: $ _____________ Do you rent your home? If yes, monthly rent amount: $ _____________ Landlord name: ______________________________ Landlord phone #: ___________________ Do you have a government rent subsidy or live in subsidized housing? ___ Yes ___ No Is heat included in your rent? ___ Yes ___ No Is electric included in your rent? ___ Yes ___ No If you pay heat or electric costs directly to a company, please complete the information below: Heating company: _______________________________________________________________ Acct. #: _____________________ Name on Acct.: ______________________ Electric company: _______________________________________________________________ Acct. #: _____________________ Name on Acct.: ______________________ Did you close your accounts with your other vendors? __ Yes __ No (If no, you should do so.) Have you received a final bill from them? ___ Yes ___ No Example 2 Refund letter/form: [Date] [EAP agency name] [Agency address] [EAP phone number] [Primary Applicant Name] Household #: [EAP HHD #] [Household Address] Dear [Primary Applicant Name]: We received a refund from: [energy vendor name] In the amount of: $ [amount of refund] Please provide updated information about your living situation so we can process your refund. The program is on a first come, first served basis and funding availability is not guaranteed, so it is important that you respond promptly. This is the only notification you will receive. Please answer the following questions and return this sheet immediately. Thank you. What is your current physical address: House number and Street: _______________________________________________________ City, State, Zip: _________________________________________________________________ What date did you move to the new address listed above? _____________________________ What is your current mailing address? ______________________________________________ What county do you live in? ________________________________ Current phone number: ___________________________________ List everyone who currently lives with you (first and last names): _________________________ ______________________________________________________________________________ ______________________________________________________________________________ Own home or rent? Monthly mortgage or rent amount: $ __________. (If you own go to #10.) Landlord name and number______________________ Type of Housing: __________________ Do you have a government rent subsidy or live in subsidized housing? _____ Yes _____ No Is heat included in your rent? ______ Yes ______ No Is electric included in your rent? ______ Yes ______ No If you pay heat or electric costs directly to a company, please list your NEW heating and electric companies, account numbers, and name on the account below: Heating company: _______________________________________________________________ Acct. #: _____________________ Name on Acct.: ______________________ Electric company: _______________________________________________________________ Acct. #: _____________________ Name on Acct.: ______________________ Example 3 Refund letter/form: [Date] [EAP agency name] [Agency address] [EAP phone number] [Primary Applicant Name] Household #: [EAP HHD #] [Household Address] Dear [FIRST NAME LAST NAME], Your energy company  MERGEFIELD VENDR [VENDOR & ACCOUNT NUMBER] returned your Energy Assistance Program (EAP) grant, due to [REFUND REASON]. This may have happened because: You moved and the vendor is unable to locate you. You changed vendors or Apt. #. Your account number or the name on the account changed. You moved into a place where heat & electric is included in your rent. You moved in with someone. You moved into another county or state. Please fill out the attached CHANGE OF ADDRESS / INFORMATION form and attach copies of your current energy bill(s) or contact us with your new information as soon as possible. If we hear from you while program funds are still available, we may be able to transfer your EAP grant to your new energy bill if your account is active and is eligible with your new housing situation. The remainder of your Energy Assistance grant is [$ REMAINING GRANT]. The program is administered on a first come, first serve basis and funding availability is not guaranteed. This is the only notification you will receive. Thank you in advance for your timely response. Energy Assistance [EAP phone number] Attachment: CHANGE OF ADDRESS / INFORMATION form Example 3 continued: For office use only: HH#: [EAP HHD #] STAFF: [EAP Staff name] CHANGE OF ADDRESS / INFORMATION form Name: ______________________________________________________ Please print your new information: I moved in with someone. No Yes I moved into another county or state. No Yes I moved to a new address or changed apt. No Yes (please fill out the following) Date moved in: ___________________________________ New address: ____________________________________________________ City, State, Zip: ___________________________________________________ County: ______________________________________ Phone: _____________________________ Other phone: ______________________ Housing information: Own _____ Rent _____ Monthly rent/mortgage: $________ Housing type: House ______ Townhouse ______ Mobile home _____ Apartment ______ Condo ______ Duplex ______ Other: ____________________________ Landlords name: ____________________________ Landlords phone #: ____________ Additional info: Do you receive a rent subsidy (Section 8)? No Yes Is your heat included in your rent? No Yes Is your electricity included in your rent? No Yes Please list your energy companies and send a copy of your new bills. If you do not know your account number you need to contact the energy company and get one. Please contact your new heat and electric companies to set up your accounts before returning this form to us. Heat Company: _______________________ Electric Company: _____________________ New Acct #: _________________________ New Acct #: __________________________ Name on Acct: _______________________ Name on Acct: ________________________ Previous address information: Previous address: ____________________________________________________ City, State, Zip: ______________________________________________________ County: _____________________________________ What would you like us to do if you have grant money that was refunded from your previous energy company? (Sorry, we cannot send you a check, we can only transfer funds to your new energy company.) 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