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2021/2022 Heat From His Heart Application

Confidential furnace replacement / repair program application for needy families in Stark and Wayne Counties.

First Name of Person Submitting Application:

Last Name of Person Submitting Application:

Email:

Name of Organization Submitting Application:

Street Address

City

Region/State/Province

Postal / Zip code

Home Phone

Work Phone

Cell Phone

Applicant Information

First Name:

Last Name:

Number of Children:

Age of Applicant:

Home Phone:

Employed:

Yes

No

Work Phone:

Cell Phone:

Current Employer:

Length of Employment:

If currently not employed, reason:

Personal References

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

Residence / Furnace Information

Do you own your own home?

Yes

No

Age of Home:

How long have you lived there?

Number of people living in your home, including yourself:

Adults:

Children:

Type of Furnace:

Gas

Oil

Electric

Heat Pump

Don't Know

Does your home have radiators?

Yes

No

Don't Know

N/A

Current Furnace:

Working

Not Working

Photo of Furnace:

Upload File

Upload supported file (Max 15MB)

Describe any details of furnace performance/problems:

Describe any circumstances that may demonstrate any unusual or deserving situation that the Board should take into consideration:

How did you hear about us?

Thanks for submitting!

Contact Us

5483 Alabama Ave SW | Navarre, OH 44662

derek@heatfromhisheart.com | Tel: 330-806-4547

Thanks for submitting!

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