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HWAP Referral
First Name
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Last Name
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Phone
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Address
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City
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Do you live within city limits?
Yes
No
County of Residence
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Erie County
Huron County
Ottawa County
Sandusky County
Seneca County
Wood County
State
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Zip Code
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Email address
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Electric Provider
AEP
First Energy
Municipality
Other
Ownership (Select one)
*
Own
Rent
Land Contract
What type of home do you live in?
Single family
Duplex
Triplex
Mobile home
Other
Have you applied for HWAP before?
Yes
No
How many people 18 and over are there in the household?
*
Income for all occupants over 18 years old (Select all that apply)
Self-Employed
Employed
Social Security\SSI\SSD
Public Assistance- ADC\TANF
Unemployment
Workers Compensation
Child Support
Pensions
No Income
How did you learn about our program?
Facebook, Instagram or other Social Media
Family or Friends
GLCAP Staff Member
Newspaper
Social Service Agency (Dept. of Job & Family Services, OhioMeansJobs, etc.)
Television or radio
Other
Please choose where we may send an application.
Email
Home address
I consent to receive text messages from GLCAP
Yes