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2009/2010 Warm The Heart Application Form

Confidential Furnace Replacement Program Application for Delaware’s Needy Families

You may submit a 2009/2010 Warm The Heart application in any of the following ways:

• Download a printable application (Adobe PDF format).  Completed forms may be faxed to us at 302-762-4034.
• Complete and submit the online entry form below.
• Pick up an application at any of the locations listed at the bottom of this page.

2009/2010 Warm The Heart
Online Application Form

By submitting this application, I understand that completing this application does not guarantee an approval by the selection panel to receive a replacement furnace and no warranties of any kind are made.

All applications for Warm The Heart must be received by January 30, 2010. This deadline will not be waived or extended.

Please answer all questions as thoroughly as you can.

Name of Person Submitting This Application

1. Title -Select One- Mr. Mrs. Ms. (required)
2. First Name(required)
3. Last Name(required)
4. Address 1(required)
5. Address 2
6. City(required)
7. State -Select One- DE PA MD (required)
8. Zip Code(required)
9. Email(valid email required)
10. Home Phone (w/ Area Code)(required)
11. Work Phone (w/ Area Code)
12. Mobile Phone (w/ Area Code)

Applicant Information

1. Title -Select One- Mr. Mrs. Ms. (required)
2. First Name(required)
3. Last Name(required)
4. Address 1(required)
5. Address 2
6. City(required)
7. State -Select One- DE (required)
8. Zip Code(required)
9. Home Phone (w/ Area Code)(required)
10. Work Phone (w/ Area Code)
11. Mobile Phone (w/ Area Code)
12. Email
13. Are You Currently Employed? -Select One- Yes No (required)
14. If Employed, Name of Current Employer
15. If Employed, Length of Employment
16. If Not Employed, Please Give Reason
17. Annual Income -Select One- Less than $10,000 $10,000 - $20,000 $20,000 - $40,000 $40,000 - $50,000 $50,000 and above (required)

Personal References (List TWO)

1. Reference #1(required)
2. Relationship(required)
3. Phone Number(required)
4. Reference #2(required)
5. Relationship(required)
6. Phone Number(required)

Residence/Furnace Information

1. Do You Own Your Own Home? -Select One- Yes No (required)
2. Age of Home in Years(required)
3. How Long Have You Lived in Your Home?(required)
4. Number of Adults in Your Home
   Including Yourself(required)
5. Number of Children in Your Home(required)
6. What Type of Furnace Do You Have? -Select One- Gas Oil Electric Other (required)
7. Does Your Home Have Radiators? -Select One- Yes No (required)
8. If Oil, is Gas Service Available? -Select One- Yes No Don't Know (required)
9. Is Your Current Furnace Working? -Select One- Yes No (required)
10. Age of Furnace(required)
11. Describe any details of
    furnace performance/problems.(required)

Applicant's Need for Assistance

1. Describe briefly the financial situation
   and need of the family.(required)
2. Describe any circumstances that may
   demonstrate any unusual or deserving
   situation that the selection panel
   should take into consideration.(required)

 

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Pick Up an Application at Any of the Following Locations:

IN WILMINGTON, DE:

• Neighborhood House, 1218 B Street, Wilmington, DE 19801 
• Peoples Settlement Association  408 E. 8th Street, Wilmington, DE 19801 
• Latin American Community Center  403 N. Van Buren St., Wilmington, DE 19803 
• West End Neighborhood House, Inc.  710 N. Lincoln Street, Wilmington, DE 19805 
• Kingswood Community Center, Inc.  2300 Bowers Street, Wilmington, DE 19802 
• Police Athletic League of Wilmington  3707 N. Market Street, Wilmington, DE 19802 
• Nehemiah Gateway Community Center  201 West 23rd St., Wilmington, DE 19802 
• Wilmington Senior Center  1901 Market Street, Wilmington, DE 19802 

 

IN NEW CASTLE COUNTY, DE:

• Absalom Jones Senior Center  310 Kiamensi Road, Wilmington, DE 19804 
• Rosehill Community Center  19 Lambson Lane, New Castle, DE 19720 
• New Castle County Department of Community Services, James H. Gilliam Sr. Building, 77 Read’s Way, New Castle, DE 19720 
• Garfield Community Activity Center  26 Karlyn Drive, New Castle, DE 19720 
• Appoquinimink Community Activity Center  645 N. Broad Street, Middletown, DE 19709 
• Bear Library  101 Governor’s Place, Bear, DE 19701 
• Claymont Library  3303 Green Street, Claymont, DE 19703 
• Elsmere Library  30 Spruce Avenue, Wilmington, DE 19805

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Horizon Services has been proudly meeting the plumbing, heating, air conditioning, drain cleaning, sewer & water line and system installation and replacement needs of businesses and homeowners in Delaware, Southeastern Pennsylvania and Maryland since 1989.