Declaration of Household Income

Fill out the online application below or download and print the DHI PDF

"*" indicates required fields

This form is to be used for:

Zero income applicants and/or household members who are 18 years of age and over.
Regular informal payments received (such as an informal child support agreement).
Other self-declard income or benefits.

Section 1

Name*

First Last

Who will be signing the Energy Assistance Application?*

Section 2

How much money did you receive in the last month either in cash, check or direct deposit?*

If any was received, who provided you the money? What is the source of the money?*

If any was received, how many months have you received this money?*

Section 3

Rent, Food & Utilities (Fill out completely ONLY if adjusted gross income is zero)

How much is your household required to pay for rent/mortgage?

Does your household get help paying rent/mortgage?

Yes

Who helps pay?

When was the last rent/mortgage payment paid by the household?

Where did the money come from to pay that rent/mortgage payment?

If someone is giving you money to pay your rent/mortgage, how many months have they been helping you?

How did you pay for food last month?

How much are the estimated monthly utility costs?

If they were paid last month, where did the money come from to pay for the utilities last month?

If someone is giving you money to pay your utility costs, how many months have they been helping you?

Section 4

Certify Statement*

By signing this form electronically, I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I am signing this statement under penalty of prosecution if I knowingly give false information to receive assistance for which I am not eligible.

By checking this box and typing my name below, I am electronically signing this form.

Signature of Self-employed Person*

Date*

Hidden

For Office Use Only: Countable income total and description summary

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.