TSA/WAFF Application 2020/Last revised 01.20
Washington Area Fuel Fund (WAFF) Assistance Application 2020
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.) Primary source of heat: (Please check one)
Gas Electric Oil Coal/wood Propane/Bottled Other
5.) Name of utility company for which you are seeking assistance: __________________________
Account Number: _______________________________ Total Amount Due: _______________
6.) Is the head of household currently employed? Yes _____________ No _________________
(If yes, please provide documentation to verify employment of the head of household.)
7.) How many household members over the age of 18 are employed? _____________________
(Please provide documentation to verify employment for all other employed household
members.)
8.) Have you received assistance from WAFF funds since January 2020? Yes ______ No ______
9.) Please explain your reason for needing assistance with your primary heating source: _______
_____________________________________________________________________________________
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: _________________________
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome