Saunteel Jenkins. Dear Friend,

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1 Dear Friend, The Heat and Warmth Fund (THAW), a leading provider of utility assistance, wants to help keep your family safe and warm. If you are a Michigan federal employee who has recently been furloughed due to the 2019 government shutdown and is struggling to pay your utility bill(s), you can apply for assistance online at or by using a printable application. HOW TO APPLY: 1. Review the Program Guidelines to see if you meet the eligibility requirements. 2. Complete an application and include copies of all supporting documents. (Refer to the Document Checklist) 3. Submit your application online at OR 4. Mail or Drop off the completed application to THAW for review and processing. The Heat and Warmth Fund 535 Griswold St., Suite 200 Detroit, MI Once THAW receives your completed application, it will be reviewed by our Utility Assistance Center, and an approval or denial letter will be mailed to your home. If you are approved, the amount of assistance payment will be included in your letter. It may take up to 30 days for the assistance payment to be reflected on your utility account. We are here to help. If you have questions, please visit our website at or call THAW (8429) to speak to a THAW Utility Assistance Specialist. Thank you, Saunteel Jenkins Saunteel Jenkins, MSW Chief Executive Officer The Heat and Warmth Fund IMPORTANT Completing and/or submitting this application does NOT guarantee THAW utility assistance payment; does NOT prevent shut-off; and does NOT guarantee services will be restored. Assistance funds are limited and distributed on a first-come, first-serve basis. INCOMPLETE APPLICATIONS OR APPLICATIONS WITH MISSING DOCUMENTS WILL NOT BE PROCESSED.

2 Please use this checklist to make sure you are including all appropriate information in order to process your application. Completion of this application does not prevent shut-off or guarantee that your services will be restored. Failure to provide supporting documentation will delay this process. Incomplete applications will not be processed. APPLICATION DOCUMENT CHECKLIST Completed THAW Application: Application MUST be signed by the applicant x Provide a copy of your valid federal government employee ID or recent federal goverment pay stub. Copy of valid photo ID for account holder: (i.e. Driver s license or state issued ID) The address on the ID must match the service address on the account Copy of your most recent utility bill 2019 Furlough Utility Assistance Program Guidelines Eligibility: Applicant must be a federal furloughed employee Account must be in the applicant's name; if not the applicant must live in the home and accept responsibility for the bill Account must be residential (not a commercial account) Unauthorized usage and security fees will not be covered Account must have a past due balance 2

3 2019 Furlough Utility Assistance Application Applicant Information: First Name: Last Name: Phone Number: Address: County: Zip Code: City: Applicant s Date of Birth: Applicant s Gender: Male month/day/year Female Applicant s full SSN: Race: Arab Black/African-American Hispanic Native American Caucasian Other Household Income: Please check all sources that apply and provide a copy of all third party documents used to verify household income: Social Security benefits (RSDI) Disability benefits Employment/Earned Income Supplemental Security I ncome (SSI) Self-employment income Workers Compensation Money from family/friend Pension/retirement benefits Unemployment Veteran s benefits/military Child support DHS Cash (FIP) allotments Other, please list (ex: lottery winnings) Rental income or a land contract, mortgage or other payment payable to a household member Total Monthly Household Income $ 3

4 Household Information (Continued): Total Number in Household: Number of Seniors (60 and over): Number of Adults (18-59): Number of Children (under 18): Number of disabled individuals in household? Number of pregnant individuals in household? Ages of Seniors: Ages of Children: List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include date of birth and citizenship for each member. Attach extra pages if you need to include additional members. Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No 4

5 Household Information (Continued): Do you receive (Check all that apply): Food Stamps? Medicaid? State Emergency Relief (SER)? Do you own your home? Yes No Amount you paid toward your utility bill in the last 6 months $ (do not include assistance payment from DHHS or other agencies) Type of Household (where the applicant resides): Single Adult/No Children Single Parent/Minor Children Single Parent/Adult Children Single Parent/Minor and Adult Children Single Parent/Adult Child(ren) and Grandchildren Husband/Wife/No Children Husband/Wife/Minor Children Husband/Wife/Adult Children Husband/Wife/Minor and Adult Children Two Adults/Minor Children Other: Reason for Application (check all that apply): Received shut-off notice Crisis/Unexpected Expenses Reduced wages/work hours Illness/Medical Hardship Services are already shut off Other: Loss of job Education Completed: Some High School High School Diploma Some College Associate Degree Other: GED Trade School Bachelor s Degree Advanced Degree IMPORTANT: Applicant must sign below. Authorization to Release: I affirm the information provided is true, subject to verification, and if false, I will be denied THAW assistance. I understand that THAW Fund does not guarantee payment of funds, even if preliminary approval is granted. I hereby release THAW Fund, its employees, officers, directors and its partnering agencies from any liability in connection with the application and payment or nonpayment of any funds. I give permission to this agency, THAW and utility vendors to request and receive information from other parties as necessary to reach a determination on my request for utility assistance. I have read, understand and agree to these conditions and requirements. SIGNATURE REQUIREMENT Please sign below. Signature of applicant Date By signing this form, the applicant is stating all information is correct to the best of their knowledge 5

6 Household Needs Assessment Questionnaire THAW is requesting your completion of this questionnaire to help us learn more about what you or other household members may need. This survey can help connect you to resources or services in your area through our network of partner agencies and allow us to provide you with information on accessing those resources. Please check all areas for preferred assistance/wraparound services: Clothing assistance Employment & Job Training Food pantry Free tax preparation Health & Wellness/Disease Prevention Rental & Mortgage Assistance Transportation Assistance Weatherization Youth Programming Daycare & early childhood education Family Budgeting Mental Health Counseling Tutoring Education Emergency medical or financial assistance First-time home buying & affordable housing Meals on wheels Other 1.) What is your preferred form of communication regarding wraparound services/programming? Telephone ( ) 2.) What other feedback would you like to provide on this needs assessment questionnaire? Thank you for your participation! 6