LIHEAP  Emergency Assistance Request
You must be currently receiving a LIHEAP Benefit this season to be eligible for Emergency Assistance and owe more than $300.
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Email *
First Name (LIHEAP applicant)  *
Last Name *
Phone Number *
Last 4-digits of Social Security Number *
Zipcode *
Do you have a shut off notice, or past due amount of at least $300.00 *
Required
How much is your current bill? *
How much is your past due amount? *
Are you currently enrolled in the Fresh start program? *
Required
If you are enrolled in the Fresh Start Program- What is the amount you owe? *
How did you apply?
Utility Provider *
County *
Agency *
 Official Use Only- NJ 211 Staff name
A copy of your responses will be emailed to the address you provided.
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