Orange County fuel fund Program  Version 2.4 - 3/1/2023

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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.

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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‚Äôs 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....

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