WYN - Warm Your Neighbor

Applicant(s) Name:*

Address:*

City, State, Zip:*

Phone:*

Addt'l Phone:*

Employer:*

If Joint Application - Second Applicant's Employer:*

What is the PRIMARY heating source of your home?*

Propane
Natural Gas
Electric
Wood

Who is your PRIMARY Heating Provider?*

Address:*

Phone:*

Has your heating source been shut off or have services been disconnected?*

Yes
No

If yes, please explain why:*

Have you received any other assistance with your heating needs?*

Yes
No

If yes - From Where?*

How Much?*

Primary reason for requesting "WYN" assistance:*

Medical
Employment
Other

Please provide specific information on why you are requesting "WYN" funds.*

Complete below only if you are submitting this application on behalf of someone else:

Applicant(s) above recommended by: Your Name:

Address:

Phone:

Relationship to Applicant(s):

City, State, Zip:

By signing below, I agree the information provided on this application is true and accurate. I understand and agree to allow the Warm Your Neighbor, or "WYN", Committee / B&B Propane to contact my energy supplier or any organization listed above as part of the application process and hereby give all parties permission to discuss my account information on file. I understand if I fail to cooperate with "WYN" Committee requests for information, my application for "WYN" funds may be denied. I have received the second page of application for further details on the "WYN" review process.

Applicant Signature

Date

Applicant Signature

Date

Warm Your Neighbor ("WYN") Application

Complete below only if you are submitting this application on behalf of someone else: