Home Heating Relief Application
A Community program sponsored by The Mountaintop Interfaith Community and Wellness Rx Charitable Trust
About this program:
This program is for the winter season of 2022-2023 for mountaintop residents in need. Maximum allotment per applicant will be $200. Payment will be made directly to your fuel/service provider. We will review all applications within 72 business hours and reach out to each applicant to advise on our decision. Please make sure to provide a phone number where you can be reached between 9:00am and 5:00pm Monday through Friday. We will not be processing applications on the weekends.
Street Address Line 2
State / Province
Postal / Zip Code
Please enter a valid phone number.
If renting, please provide landlords name, address, and phone number (put N/A if non-applicable):
If other please explain.
How many people live in your household?
Please list the names and ages of everyone living in your household:
What is your household's yearly income?
$0 - $15,000
$15,001 - $25,000
$25,001 - $35,000
$35,001 - $45,000
$45,001 - $55,000
$55,001 - above
How do you heat your home?
If other, please explain.
Name of fuel supplier
Are you currently without heat?
Do you have heat, but are unable to afford your current bill or to refill?
Are you currently receiving or are you eligible for HEAP? (Home Energy Assistance Program in NY)
Please give us a brief description of your current heating needs and situation.
By sending this electronically, I acknowledge that I have completely read this questionnaire and comprehend it fully. I understand that applying does not ensure approval and that untruthful answers or failure to comply with the requirements of this application can result in the forfeiture of any assistance for home heating. I certify that the above information is correct, and I understand that the information will be verified. I understand that by submitting this form electronically, I agree to release and covenant to hold harmless both the Mountaintop Interfaith Community Organization, and the Wellness Rx Charitable Trust, it's Trustee and Manager from any claims, damages, costs, or actions incurred with deliveries, or services provided by outside vendors.
Should be Empty: