GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES
GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Division of Family Assistance – Certification Unit Rev. 4/2022 St. Croix Office Division of Family Assistance, Certification Unit 4102 Mars Hill Frederiksted, VI 00840-3376 (340) 772-7100 certoffice.stx@dhs.vi.gov St. Thomas/St. John Office Division of Family Assistance, Certification Unit 1303 Hospital Ground, Suite 1 St. Thomas, VI 00802-6722 (340) 774-0930 certoffice.stt@dhs.vi.gov Energy Crisis Assistance Program Last Name First Name M.I. Date ______________________ Social Security Number: ___________________ Employer: _______________________________ Address: Home: ___________________________________ _________________________________________ Mailing: _________________________________ _________________________________________ Contact number(s): ________________________ Age: _____ Total Number in Household _______ Income: __________________ Total Household Income: ___________________ ___ Copy of Income Attached Supplier Information Account Number: ______________________ Meter Number: ________________ …
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GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES Department of Human Services Division of Family Assistance – Certification Unit Rev. 4/2022 St. Croix Office Division of Family Assistance, Certification Unit 4102 Mars Hill Frederiksted, VI 00840-3376 (340) 772-7100 certoffice.stx@dhs.vi.gov St. Thomas/St. John Office Division of Family Assistance, Certification Unit 1303 Hospital Ground, Suite 1 St. Thomas, VI 00802-6722 (340) 774-0930 certoffice.stt@dhs.vi.gov Energy Crisis Assistance Program Last Name First Name M.I. Date ______________________ Social Security Number: ___________________ Employer: _______________________________ Address: Home: ___________________________________ _________________________________________ Mailing: _________________________________ _________________________________________ Contact number(s): ________________________ Age: _____ Total Number in Household _______ Income: __________________ Total Household Income: ___________________ ___ Copy of Income Attached Supplier Information Account Number: ______________________ Meter Number: ________________________ Meter Status __ Pending ___ Terminated Proposed termination Date _____________ Other Household Members: Name ____________Age ___ Relationship _____ Employer ________________ Income_________ Name ____________Age ___ Relationship _____ Employer _______________ Income__________ Name ____________Age ___ Relationship _____ Employer _______________ Income__________ Name ____________Age ___ Relationship _____ Employer _______________ Income__________ Direct Assistance/ Supportive Services ____ General Assistance ____ Food Stamps- Case Number _________ ____ AFDC _______________ ____ WIC ________________ ____ Other, Specify ____________________