WX
Rev. 08/2017
Department of Workforce Services
HOUSEHOLD INCOME DEFICIT STATEMENT
To be filled out by each adult household member or married couple when income is not
enough to meet basic living expenses. Answer all questions thoroughly or your
Weatherization application may be denied.
Eligibility month and year:
Why didn’t you have enough income to meet your expenses last month?
1. Check the option that best reflects your situation:
I/we did not receive any money from any source during the month above.
The money I/we received for the month above was less than our living expenses.
2. How are you getting by?
3. Does anyone help you meet your living expenses? ................................................ Yes No
If yes, what type of help and from whom?
If yes, how often, for how long, and how much $?
4. Explain how you are paying for the following needs for your household (do not list $ amounts):
Satellite/Cable/Internet:
Personal Items (soap, toilet paper, diapers, etc.):
Additional documentation may be required and must be provided within 10 days of request or your application will be
denied.
I am aware that providing false information to the HEAT program is grounds for denial of my application or may require
that I repay in full any payment made in behalf of my household from the Weatherization program. By signing below, I
hereby acknowledge and understand the information provided in this statement is true to the best of my knowledge.
..................................................................................................................................................................................................................................
In the County of , State of Utah, on this , day of , 20 ,
before me, the undersigned notary, personally appeared , who provided to me his/her identity
through documentary evidence in the form of a to be the person whose name is signed to
the preceding document, and acknowledge to me that he/she signed it voluntarily for its state purpose.
(Notary Public Seal) Notary Signature
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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