Fuel Assistance Application Cancellation/Withdrawal Request

By submitting this form, you are requesting that your application for LIHEAP in FY 2024 be withdrawn.

Date
Name
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Phone
Email
Reason for application withdrawal/cancellation request
Household members changedHousehold income changedMoved out of areaMet heating needs another wayCould not provide necessary documentsMoved to nursing home/assisted livingOther
Please enter new address and/or explain other if applicable