Colrain Wood Bank Application

All Applications are due by ----

Name*

Address*

Phone Number

Email Address

Best Way to Contact You

Phone Email

Total number of adults in household*

Ages of Adults*

Total number of children in household*

Ages of Children*

Is anyone in the household disabled?

Yes No

Have you applied for fuel assistance this year?

Yes No

(We strongly encourage you to do so: https://www.mass.gov/how-to/apply-for-home-heating-and-energy-assistance)

If you applied- were you approved?

Yes No

If no- please explain why your app. was denied.

(8000 character limit. Characters so far: 0 Word Count: 0)

What is your main source of heat?

What other sources of heat do you have?

Any additional information?

(8000 character limit. Characters so far: 0 Word Count: 0)

Include any further information you think should be considered.

Your Friday Color*

FORM IS CLOSED

Colrain