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Get and Sign Liheap Application 2013-2022 Form
Assistance Office Address
YOUR NAME AND ADDRESS
DPW USE ONLY
CRISIS
If you do not understand these instructions, contact your local county assistance office.
1
Please complete this section for the head of household.
County
*Use the codes from page 2 to help provide the details.
Name (Include Last, First Middle Initial)
CASH
Application Registration Number
Date of Birth
Sex
Social Security Number
District
Record Number
Home Address (Include Street, Apt. Number, City, State & Zip...
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