Heating Application Veteran Heating Assistance Program | Aroostook County Veteran Heating Assistance Program ApplicationPlease read ALL Eligibility requirements before completing application. Ineligible or partial applications will not be saved. Your Name(Required) First Last Your Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code How Can We Reach You?Email Address(Required) Email Address Confirm Email Address Phone Number(Required)Military Service InformationBranch of Service(Required)Select BranchAir ForceArmyCoast GuardMarinesNavySpace ForceUpload Proof of Veteran Status(Required)Max. file size: 32 MB. (DD-214, VA ID card, Military ID, State ID or driver’s license with “Veteran” label, etc.)Military Discharge Status(Required)HonorableDishonorableGeneralPlease explain further if you selected "dishonorable" or "general".Income InformationNumber of People in Household(Required)12345678910+How many people currently live in your household (including yourself)?a. Salary and Wagesb. Social Security | Retirementc. Social Security | Disabilityd. Retirement | Pension (state, company or other)e. Retirement | Militaryf. Military Disabilityg. Federal or State Assistance (ACAP, general assistance, etc)Other Income | All Sources (Rental income, investment earnings, etc)Total Household Income (Please add all totals from above)(Required)Total household income should include the earnings of all individuals residing in your home. This includes all forms of income such as wages, compensation, retirement or pension benefits, disability payments, Social Security, unemployment benefits, and any other financial assistance or regular support received.Additional InformationHave you ever been convicted of a felony?(Required) Yes No If yes, please provide a brief explanation.Type of Heating Fuel(Required)Select Heating Fuel Type#2 Heating FuelKeroseneSize of Tank(Required)Level of Tank (example: half tank, almost full, empty, etc)(Required)Who is your current heating fuel provider?(Required)Primary contact for this application (if different from applicant):Primary contact phone numberPrimary contact's relationship to applicantApplicant Certification(Required)By checking this box, I confirm that all information provided in this application is true, complete, and accurate to the best of my knowledge. I understand that providing false or misleading information may affect eligibility for assistance. I Agree