Confirmation/signature Page
Your application has been filed. Please do not forget to print, sign, and mail
us this signature page.
You must have adobe acrobat reader installed which can be obtain for free at
Adobe.com or print this page.
You can check the status of your application at anytime by visting our website
again and using the Find out the Status of your Application already submitted link.
I, ________________________________, (print name) have read the information
listed on this application. I believe that it is accurate and that it
reflects my household's situation. I also give permission to the Fuel Fund-Energy Savers Program
staff and its agents to share this information with other programs which may be
able to help me. The Fuel Fund-Energy Savers Program has my permission to contact my
vendor, utility company and any other agents needed to verify information about
my account and to share information with them. I also give my permission for
contacts listed in this application to share information about my account or
case with the Fuel Fund-Energy Savers Program. I understand that information about my
application may be shared with the Department of Social Services and that the
Department of Social Services may share information about my application with
other local service providers. Failure to sign this document may cause your
application to be denied for acceptance into the Program.
______________________________________ _____________
Signature Date
If you have completed this application on-line, please print this form and fax it with your signature to (845) 344-1889 (Fax). You may also mail the form to RECAP Attn: Fuel Fund Serving Orange County at 40 Smith Street, Middletown, NY 10940, attn Fuel Fund Program Coordinator. To reach the Fuel Fund, contact us at (845) 421-6280 (phone). The Fuel Fund will notify some or all of the following organizations that
your application is pending: Salvation Army, Catholic Charities, People to
People, the Orange County Department of Social Services, and your utility’s
energy fuel fund (if one is open). We encourage you to seek assistance with
these organizations if you have not already. Failing to apply for other
assistance may hurt your chances of receiving help from the Fuel
Fund-Energy Savers program now and in the future.
DON'T FORGET TO PRINT SIGN AND MAIL THIS
SIGNATURE PAGE....
T H A N K Y O U