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| Received Date |
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Utility Expense Details
| Utility Expense Type |
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| Total Expense Amount | Frequency | ||||||
|---|---|---|---|---|---|---|---|
| Start Date |
| End Date |
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| Low Income Energy Assistance Payments |
Utility Expense Details
If the utility is a case participant, please select from below.
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If the utility is not a case participant but is registered on the system, please select from below.
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If the utility is not registered on the system, complete the utility details below.
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Reimbursement Details
| Reimbursement Type | |||
|---|---|---|---|
| Reimbursement Amount |