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ECAP) from DHS? 2. y or y I or If yes, What County and Date? 3. N N 4. 5. Does any household member receive food stamps? 6. Has your home been weatherized Amount? - in the past? Y or N Y or N If no, Would you like to have information mailed to you? 8 Is any household member receiving donated foods (Food Distribution) Y or N 9. Ifno, Would you like to have a referral for this type assistance? 10. Have you had a Sudden Reduction in Income? Ifye , Please Explain: Page 3 Y o.

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