TSA/WAFF ApplicationPepco Extension 2017/Last revised 6.17
___________________________________________________________________
Washington Area Fuel Fund (WAFF) Pepco Extension Assistance Application
Name: ________________________________________Social Security (last 4): XXX-XX- ___________
Address: ____________________________________________________________________________
City: ________________________________State: ______________________Zip: ________________
Telephone: _______________________________ Email: ___________________________________
1.) Total Number of People in Household: ____________________________________________
Number of people of in the household who are:
a.) Age 18 or under __________________
b.) Age 19 60 years old __________________
c.) Over 60 years old __________________
d) List the ages of the minor children in the household _______________________________
2.) Is anyone in the household a veteran? Yes _____________ No ________________
3.) Total Household Income: _________(bi-weekly) __________(monthly)____________(annually)
4.) Pepco Assistance:
Pepco Account Number: __________________________ Total Amount Due: _______________
5.) Is the head of household currently employed? Yes _____________ No _________________
(If yes, please provide documentation to verify employment of the head of household.)
6.) How many household members over the age of 18 are employed? _____________________
(Please provide documentation to verify employment for all other employed household
members.)
7.) Have you received assistance from WAFF funds since January 2017? Yes ______ No ______
Date of prior visit: ______________________
8.) Please explain your reason for needing assistance: ____________________________________
_____________________________________________________________________________________
All information provided in this application is true and correct to the best of my knowledge. I understand that
false statements of information” could render my application invalid for funding consideration. I also understand
that completion of this application does not guarantee the granting of funds. Also, by my signature below, I
authorize The Salvation Army to gather any necessary information from additional agencies, vendors, or
individuals involved in my case in order to qualify me for these funds. This consent will expire one year from the
date below unless I indicate the withdrawal of my consent in writing to The Salvation Army.
Signature:_____________________________________________ Date: _________________________
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