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LIEAP Referral Application Request.

Name:                                       __________________________________________

Address:                                 __________________________________________

City:                                          __________________________________________

State, Zip:                              __________________________________________

I               � have    �have not received LIEAP assistance in the past.

My household includes one or more of the following.                                               

                                                                                                                       �  Senior Citizens

                                                                                                                       �  Disabled

                                                                                                                       �  Children under 6 years of age