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DWS-HCD 873
Rev. 09/2021
State of Utah
Department of Workforce Services
HEAT Program/HELP/EAF Instructions
(Home Energy Assistance Target)
AND WATER ASSISTANCE PROGRAM
Instructions for HEAT/WATER Application:
This application must be completely filled out, signed, and dated. Copies of all the following
documents must be included or your application cannot be processed.
1. Household Verifications:
• Copy of a picture identification for primary applicant
• Copies of Social Security cards for EVERYONE in the home, including children
• Copies of U.S. Customs and Immigration Services (USCIS) documents showing legal
status in the U.S. for any non-citizens
2. Income and Income Deductions Verifications:
• Copies of proof of all income received in the previous month by all household members
(check stubs, Social Security statements, retirement benefits, child support, alimony, etc.)
• If the household includes adults with no income, or if income is less than living expenses,
include completed form 880 Household Income Deficit Statement (found at
https://jobs.utah.gov/housing/scso/seal/documents/880.pdf)
• Proof of payment for any eligible medical expenses paid in the previous month
• Proof of any child support or alimony paid the previous month, if applicable
*Please note, if you are mailing an application, the previous month is the month prior to the
month the application is postmarked.
3. Energy Burden Verifications:
• Copies of the applicant’s most recent utility and/or water bills.
• A copy of the applicant’s lease if the utilities are included in the rent, or the Landlord Statement
(form 1062H) completed and signed by landlord.
4. Target Groups Verifications (additional funding is available for applicants with household
members 60 or older, disabled, or under six):
• Driver’s license or other official documentation indicating age 60 or older
• Copy of the birth certificate for a child five years old or younger in the home
• Proof of a disability, if applicable
5. Additional Documentation may be required. Relevant third parties may be contacted to verify
information provided.
Remember to include a phone number where you can be reached
if we have questions or need other documents.
Send copies only, as originals will not be returned.
If the application is not filled out correctly or is lacking documentation, it will be denied.
If your utilities or water have been disconnected or are scheduled for disconnection within
48 hours, contact your local HEAT/WATER office for instructions.
Call 801-526-9920 or 1-866-205-4357 and select the option for the county you live in.
State of Utah HEAT and WATER ASSISTANCE Program
If you live in
this county:
(listed below)
Mail or Email Application & Verifications to:
Salt Lake
Tooele
Phone: 1-844-214-3090
Fax: 801-214-3212
Box Elder
Phone: 435-723-1116
Fax: 435-723-2013
Cache
Rich
Phone: 435-713-1444
Fax: 435-752-6962
Beaver
Garfield
Iron
Kane
Washington
Phone: 435-652-9643
Fax: 435-652-8008
Davis
Morgan
Weber
Phone: 801-394-9774
Fax: 801-394-9841
Summit
Utah
Wasatch
Phone: 801-229-3855
Fax: 801-229-3670
Juab
Millard
Piute
Sanpete
Sevier
Wayne
Phone: 435-893-0745
Fax: 435-893-0750
Carbon
Emery
Grand
San Juan
Phone: 435-613-0100
Fax: 435-637-6551
Daggett
Duchesne
Uintah
Phone: 435-722-5218
Fax: 435-722-4890
Equal Opportunity Employer/Program
Auxiliary aids (accommodations) and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
1. Applicant Information
Name:
Date:
First/Middle/Last
Social Security #:
Gender: Male Female
Birth Date:
Month/Day/Year
Home Address:
City/State:
Zip:
Mailing Address if different:
City/State:
Zip:
Phone #:
Secondary Phone #:
Email Address:
2. Have you applied for HEAT assistance before? ……………………….………… Yes No
3. Ethnic background:
Native American
White
Hispanic
Black
Asian
Pacific Islander
Other:
4. Are you a US Citizen?
Yes No
If no, provide documentation of legal residency.
5. Other persons in residence. Include all other adults and children: (Continue on back if needed.)
Name (First, Last)
Relation
Birth date
mm/dd/yyyy
Age
Social
Security
Number
Sex
M / F
Income
Y or N
Citizen
Y or N
DWS-HCD 874
Rev. 09/2021
State of Utah
Department of Workforce Services
HEAT PROGRAM/HELP/EAF APPLICATION
(HOME ENERGY ASSISTANCE TARGET)
AND WATER ASSISTANCE PROGRAM
Page 2
6. Household Composition:
Child under age 6 ……...
Yes No
Receiving SNAP (Food Stamps) ..
Yes No
Age 60 and older ………
Yes No
U.S. Veteran .................................
Yes No
U.S. Citizens (all?) …….
Yes No
Handicapped/Disabled ..
Yes No
If Yes, describe disability:
Number of Adults:
Number of Children (under 18):
Total # in Household:
7. Your dwelling is a (check one):
House
Duplex
Small trailer (must have permanent address)
Mobile Home
Condo
Townhouse
Apartment (3 or more units)
Basement apartment
8. Do you rent or own your home? ………………………………………………….. Rent Own
What is your primary
heating source?
Gas
Electricity
Propane
Oil
Wood
Coal/Steam
Other
None
What is your secondary
heating source?
Gas
Electricity
Propane
Oil
Wood
Coal/Steam
Other
None
What is your primary
cooling source?
Central Air
Fan/Evaporative/Other
Window Unit
None
9. How much is your monthly rent/mortgage payment? $ ________________________________
Is your rent subsidized? ………………………………………………………………..... Yes No
10. Does your rent include utilities and/or water?..................................................... Yes No
Which utilities? __________________________________________________________________
11. HEAT payment is to be issued to the following utility vendor(s) in the percentages listed below
(100%, 50/50%, or 25/75%). The utility vendor and percentage cannot be changed after the
application is submitted. Be sure to check the account status for each utility. If you check 48 HR you
must include a copy of the 48-hour shut-off notice. For propane, check ON if you have fuel, OFF if
you are out of fuel, and 48 HR if you will run out of fuel within 48 hours. Copies of all utility bills
and disconnect notices must be sent to the HEAT/Water Assistance Agency for verification.
Name of
Utility Vendor(s)
% of
benefit
Account
Status
Utility Account
Number(s)
Name on account
(provide explanation
if not applicant)
On
Off
48 HR
On
Off
48 HR
Name of electricity vendor and account number if not included above:
Page 3
12. Have your drinking water or wastewater services been disconnected? …
Yes No
13. Do you have a disconnection/shut-off notice for your water or
wastewater services? ………………………………………………………...……
Yes No
14. Do you have fees and arrearages that are due before your water
services can be restored? …………………………………………………..……
Yes No
Fee Type (reconnection, arrears, lien, etc.)
Amount
Date water was shut
off or is intended to
be shut off
15. A Water Assistance payment is to be issued to the following water vendors if your water
services have been disconnected or you have received a water disconnection notice. Check ON if
your water bill is in good standing. Check OFF if your water has been disconnected or 48 HR if you
have a disconnection notice. Copies of all water bills and disconnect notices must be sent to
the Water Assistance/HEAT Agency for verification.
Name of
Water Vendor
Water billing type
(drinking, wastewater,
ground water,
storm water)
Account
Status
Water
Account
Number
Name on
Account
On
Off
48 HR
On
Off
48 HR
On
Off
48 HR
On
Off
48 HR
16. Income: Indicate which sources of income and/or assistance you and anyone living in your
household receive. Attach all pay stubs and documentation of all other income for LAST MONTH.
Any adults in the household with no income or net business profit must complete and include form
880 Household Income Deficit Statement found at:
https://jobs.utah.gov/housing/scso/seal/documents/880.pdf.
Income documented is for the month of:
Page 4
Earned Income
Type
Y / N
Name of
Recipient
Date
Paid
Gross
Amount
How often is
income
received?
(weekly, bi-
weekly, twice
monthly, monthly)
Employment
Y N
Employment
Y N
Employment
Y N
Employment
Y N
Self-Employment
Y N
Self-Employment
Y N
Unearned Income
Type
Y / N
Name of
Recipient
Date
Paid
Gross
Amount
How often is
income
received?
(weekly, bi-
weekly,twice
monthly, monthly)
Social Security,
SSI, SSD
Y N
Social Security,
SSI, SSD
Y N
Social Security,
SSI, SSD
Y N
Unemployment
Y N
Unemployment
Y N
Alimony
Y N
Annuity
Y N
Child Support
Y N
Reverse Mortgage
Payments
Y N
Pension
Y N
Trust Payments
Y N
Rental Property
Y N
Retirement
Y N
General Assistance/
other benefit
payments
Y N
Veterans Benefits
Y N
Workers Comp
Y N
OTHER
Y N
Attach additional sheet if needed to provide information from
all income sources for all household members.
Page 5
17. Medical Deductions: List any health, dental, or vision insurance premiums, payments for
prescription medicines, oxygen, glasses/contacts, hearing aids, and payments to doctors, hospitals,
or medical/dental clinics paid LAST MONTH. All receipts must be paid in the same month as the
month of income listed in number 16. (Attach additional sheet if needed.)
Name of Person
Type of Medical
Expense
Proof of Payment
Date Paid
Amount
Paid
18. Alimony/Child Support Deductions: Did you or anyone in your household pay alimony or child
support LAST MONTH? …………………………………………………………………… Yes No
If yes, you must include copies of the receipts with this application. All receipts must be paid in the
same month as the month of income listed in question 16.
DECLARATION: I understand that neither the vendor nor the percentage of my HEAT/Water
payment may be changed. By signing this application, I certify under penalty of perjury that the
information I provided on this application is true, and that giving false information may result in me
paying the difference between any eligible and ineligible amounts. I agree to cooperate with state
and federal officials in any review of my application and to provide information necessary to verify
any statement herein. I give permission for my utility companies to provide my billing and usage
information to the state of Utah and to local HEAT/Water agencies to determine eligibility. I hereby
authorize HEAT/Water program officials to make inquiry of persons, companies, financial
institutions, and other state and federal agencies to assist in the processing of my application. I
understand that if I do not provide the necessary information to establish my eligibility within 10
days from this date that my application may be denied. I further understand that if federal
HEAT/Water funds are exhausted prior to processing this application, the State of Utah is under no
obligation to make payment. I understand that if my application is denied or if the local office has
failed to act upon my application within 45 days, I have the right to request a Fair Hearing. I verify
that, if eligible, I would like to receive the Rocky Mountain Power (RMP) HELP discount program
and Dominion Energy Energy Assistance Fund (EAF) credit.
/s/
Signature
Date
If you believe you have been treated unfairly by the HEAT/Water Assistance program,
call 866-205-4357 for assistance.
Equal Opportunity Employer/Program
Auxiliary aids (accommodations) and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals
who are deaf, hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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Completed 17 January 2022

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