DWS-HCD 880 Heat Agency:
Rev. 08/2024
State of Utah Case #: ________________________
Department of Workforce Services
HOUSEHOLD INCOME DEFICIT STATEMENT
To be filled out by each adult household member or couple when income is not enough
to meet basic living expenses. Answer all questions thoroughly or your HEAT application
may be denied.
Name(s): Eligibility Month (Last Month):
1. Why didn’t you have enough income/any income to meet your expenses last month?
Explain your situation:
2. How did you pay the following household expenses last month?
Housing:
Utilities:
Groceries/Food:
3. Did anyone help you meet your household expenses last month? Yes No
If Yes:
From whom?
How much (dollar amount)?
What type of help?
Was this cash assistance or were payment(s) made directly to a utility vendor, mortgage
company, landlord, etc? Please explain.
I am aware that providing false information to the HEAT program is grounds for denial of my application or may
require that I repay in full any payment made on behalf of my household from the HEAT program. By signing below, I
hereby acknowledge and understand the information provided in this statement is true to the best of my knowledge.
Additional documentation may be required and must be provided within 10 days of request or your application will be
denied. Examples of additional documentation may include but are not limited to copies of bank statements for the
past three months, tax transcripts, documents from past or present employers, loan documents, statements from
friends, family, or organizations providing assistance, and any other documentation deemed necessary.
Signature: /s/ _______________________ Date:
Please mail, email, or fax completed form to your county HEAT agency listed here:
[Link]
Internal Applicant Name:
Use Only: HEAT Application #: HEAT Worker:
Equal Opportunity Employer/Program
Auxiliary aids (accommodations) and services are available upon request to individuals with disabilities by calling 801-526-9240. Individuals who are deaf,
hard of hearing, or have speech impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
