#DSS-01-25 | Apply for Home Energy Assistance Program | [O]

#DSS-01-25 | Apply for Home Energy Assistance Program | [O]

1 by Matthew Kaufman

CITY OF LOS SANTOS INVITES APPLICATIONS FOR THE PROGRAM OF:
Home Energy Assistance

‎Program No.‏‏‎ ‎#DSS-01-25‏‏‎‎‏‏

Status OPEN

Department LS Social Services

Location1827 Hill Street, Commerce, LS 206

Application Template Preview

2 by Matthew Kaufman

‎

City of Los Santos
Home Energy Assistance Application

PERSONAL INFORMATION

- Forename & Surname: Answer Here
  Date of Birth: Answer Here
  Residence Address: Answer Here
  Phone Number: Answer Here
  E-mail address: Answer Here
  
  Select your citizenship status:
  - U.S. Citizen
    Non-U.S. Citizen
- Select your gender:
  - Male
    Female
    Other

HOUSING INFORMATION

Housing status: Owner Tenant
Type of residence: Single-family house | Apartment | Other
Monthly cost of rent: Answer Here
Main heating source: Natural Gas | Oil Fuel | Electricity | Other
Heating Company: Answer Here

INCOME INFORMATION

Do you have any income?:
If yes, how much do you receive per month?: Answer Here
Sources of income: Salary | Welfare | Pension | Other

HOUSEHOLD MEMBERS

Forename & Surname: Answer Here
Date of Birth: Answer Here
Relationship living with applicant: Answer Here

ADDITIONAL INFORMATION

Do you have any disabilities or medical conditions?: Yes / No
If yes, please explain: Answer Here
Do you receive any other benefits?: Yes / No
If yes, please specify: Answer Here

Declaration:
I, [Your Name], hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in disqualification from receiving assistance.

Signature:
Date:

(( OUT OF CHARACTER ))

- Country of Residence & Timezone: Answer Here
  
  Discord ID: Answer Here
  
  Please list all your characters and their levels:
  - Name Surname
  - Name Surname
  - ...

Template

3 by Matthew Kaufman

Application Subject

Code: Select all

#DSS-01-25 - Home Energy Assistance | Firstname Lastname

Application Form

Code: Select all

[divbox=white][center][img]https://i.imgur.com/b9f9JTN.png[/img][/center]‎
[center][size=110]City of Los Santos[/size]
[size=130][color=#000000][b]Home Energy Assistance Application[/b][/color][/center][/size]
[list=none][divbox=black][center][color=#FFFFFF][b]PERSONAL INFORMATION[/b][/color][/center][/divbox][/list]
[list=none][list=none]


[b]Forename & Surname:[/b] [i]Answer Here[/i]
[b]Date of Birth:[/b] [i]Answer Here[/i]
[b]Residence Address:[/b] [i]Answer Here[/i]
[b]Phone Number:[/b] [i]Answer Here[/i]
[b]E-mail address:[/b] [i]Answer Here[/i]

[b]Select your citizenship status:[/b]
[list=none]

[cb][/cb] U.S. Citizen
[cb][/cb] Non-U.S. Citizen
[/list][/list]
[list=none]
[b]Select your gender:[/b]
[list=none]
[cb][/cb] Male
[cb][/cb] Female
[cb][/cb] Other
[/list][/list][/list]
[list=none][divbox=black][center][color=#FFFFFF][b]HOUSING INFORMATION[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Housing status:[/b] Owner[cb][/cb] Tenant [cb][/cb]
[*] [b]Type of residence:[/b] Single-family house [cb][/cb] | Apartment [cb][/cb] | Other [cb][/cb]
[*] [b]Monthly cost of rent:[/b] [i]Answer Here[/i]
[*] [b]Main heating source:[/b] Natural Gas [cb][/cb] | Oil Fuel [cb][/cb] | Electricity [cb][/cb] | Other [cb][/cb]
[*] [b]Heating Company:[/b] [i]Answer Here[/i]
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]INCOME INFORMATION[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Do you have any income?:[/b] [cb][/cb] 
[*] [b]If yes, how much do you receive per month?:[/b] [i]Answer Here[/i]
[*] [b]Sources of income:[/b] Salary [cb][/cb] | Welfare [cb][/cb] | Pension [cb][/cb] | Other [cb][/cb]
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]HOUSEHOLD MEMBERS[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Forename & Surname:[/b] [i]Answer Here[/i]
[*] [b]Date of Birth: [/b][i]Answer Here[/i]
[*] [b]Relationship living with applicant:[/b] [i]Answer Here[/i]
[/list]


[list=none][divbox=black][center][color=#FFFFFF][b]ADDITIONAL INFORMATION[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Do you have any disabilities or medical conditions?:[/b] Yes [cb][/cb] / No [cb][/cb]
[*] [b]If yes, please explain:[/b] [i]Answer Here[/i]
[*] [b]Do you receive any other benefits?: [/b]Yes [cb][/cb] / No [cb][/cb]
[*] [b]If yes, please specify:[/b] [i]Answer Here[/i]
[/list]
[hr][/hr]
[br][/br]
[b]Declaration:[/b]
I, [b][Your Name][/b], hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in disqualification from receiving assistance.
[br][/br]
[b]Signature:[/b]
[b]Date:[/b]
[list=none][divbox=black][center][color=#FFFFFF][b](( OUT OF CHARACTER ))[/b][/color][/center][/divbox][/list]
[list=none][list=none]
[b]Country of Residence & Timezone[/b]: [i]Answer Here[/i]

[b]Discord ID[/b]: [i]Answer Here[/i]

[b]Please list all your characters and their levels[/b]:
[list=none]
[*] Name Surname
[*] Name Surname
[*] ...
[/list]

[/list][/list]
[/divbox]