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Benefits Certification

Benefits Certification Form

  • Staff's Applicant Duplication of Benefits Certification

    This form must be submitted before submitting your request for Utility Assistance.
  • Please list a phone number that we can use if we need to contact you during business hours.
  • I, (Name stated above) state under penalty of perjury, that I reside at the following address (Address stated above) of the City of St. Louis, Missouri and certify I, (including all members of my household),
  • MM slash DD slash YYYY

    This section is only for staff members of Heat Up St. Louis, Inc.
  • Staff, board, or consultant
  • MM slash DD slash YYYY
  • This Document Must Be Reveiwed, Approved and Attached To The Above Client File For Audit Purposes