O 9. ADDITIONAL INFORMATION
Information reported in this section will not be used to determine your eligibility for LEAP or your payment level. This information will only be used for statistical information.
Check ( ) here if any member of your household is: 
Handicapped or disabled
Race of applicant: Hispanic White Black or African American American Indian or Alaska Native Asian

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Other
I learned about LEAP from the following source (check only one):
Friend |
1-866-HEAT-HELP (432-8435) |
Senior Center |
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LEAP Poster |
Newspaper |
Billboard |
PEAK Website |
Heating Company |
Radio |
Bus Benches |
Other |
Received Application in Mail |
LEAP Website |
Television |
|
O 10. CONSENT TO DISCLOSE CUSTOMER DATA
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•Your utility account payment history and other account details, such as utility charges, payment history, past due amounts, pending deposits, current shut-off due dates or disconnection, current life support status, payment arrangements, and history of energy assistance payments.
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Electric
Natural Gas utility meter by your utility service provider.
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Please note that:
•You are not required to authorize your utility service provider to disclose your customer data.
•Your decision not to authorize the disclosure will not affect your utility services.
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• Your utility service provider will have no control over the data disclosed pursuant to this consent, and will not be responsible for monitoring
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O 11. SIGNATURE AND CONSENT
By signing below I understand, I acknowledge and agree that:
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3.The Colorado Department of Human Services (CDHS) may use my Social Security Number to get wage data, amount of unearned income, child
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6.If LEAP repairs or replaces my heating system and I refuse to allow access to my dwelling for the purposes of completing the service
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8.I declare that the information given by me in this application is true and correct. I understand the penalty for providing false information. $SHUVRQFRQYLFWHGRIIU XGXOHQW FWLYLW\F QQRWJHW ($3 VVLVW QFHIRUWKUHH\H UVIRUWKHÀUVWFRQYLFWLRQ QGSHUP QHQWO\IROORZLQJWKH second conviction.
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Signature: __________________________________________________________ |
Date:________________ |
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If someone helped the applicant complete this application, such person must sign below. |
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If you would like to know the status of your application please call HEAT HELP at 1-866-432-8435.