Oil/Propane Assistance Application

Are you a resident of Montgomery county?

Yes

Qualifying Zip Codes: 18054, 18074, 18915, 18964, 18969, 19426, 19435, 19438, 19440, 19446, 19453, 19454, 19456, 19460, 19464, 19468, 19472, 19473, 19478, 19492, 19525.

You are not eligible for Manna's Oil/Propane Assistance Program.
Please call Community Connections for additional resources at 610-278-3522.

Select your qualifying zip code in Montgomery County

Household Information

First Name of Head of Household *

Last Name Head of Household *

Date of Birth Head of Household *

xx/xx/xxxx

Address *

City *

State

Zip *

Sex/Gender

Race

Ethnicity

Phone *

Email *

Are you a Veteran? *

Other Adults in Household

Are there any other adults in the household? *

Yes

If yes, how many?

Information for Other Adults in Household

First Name

Last Name

Date of Birth

Relationship to Primary Applicant

Sex/Gender

Race

Ethnicity

Add Remove

Minors (Under 18) in Household

Are there any minors (under 18) in the household? *

Yes

If yes, how many?

Minors (Under 18) in Household

First Name

Last Name

Date of Birth

Relationship to Primary Applicant

Sex/Gender

Race

Ethnicity

Add Remove

Monthly NET Household Income

**Please include income for all household members.**

Do you have income? *

Yes, I have income

No, I have no income (a self-declaration form will be provided to you to be completed)

Work Earnings *

Retirement/Pension *

SNAP Benefits *

Social Security Income/Social Security Disability Income *

Child Support *

Disability/Unemployment/Workers Comp *

Other *

* All income must be documented income.

Manna on Main Street is committed to safeguarding the personal information entrusted to us by our clients. In certain circumstances, we may need to contact other agencies, individuals, volunteer groups, or faith-based organizations to obtain or share information deemed necessary to assist you. This information will only be used within the context of our services to provide you with food, rental, utility, prescription, or any other financial assistance. *

I have read and understand

Manna does not discriminate based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted. *

I have read and understand

In order to coordinate services among the participating fuel assistance agencies, certain information—including your name, address, household size/composition (including number of children), LIHEAP status, details of fuel assistance received, head of household age range, employment status, tenant or homeowner status, and circumstances of need—will be shared with Gateway Housing Group, their funding partners, and participating agencies (Orion Communities, Spring Ford Project Outreach, Pottstown Cluster of Religious Communities, Manna on Main Street, and Act in Faith), with your name and address also stored in an online database for their shared use. This consent does not expire, though you may revoke it at any time by sending written notification via certified mail to Manna on Main Street, except to the extent that action has already been taken in reliance on it. By signing, you acknowledge that you have read and understood this form, and you may request a copy of your signed application for your records. *

I have read and understand

Signature *

Clear

If you are human, leave this field blank.

Oil/Propane Assistance Application

Manna’s Heating Oil/Propane Assistance Program

Apply Now

Household Information

Other Adults in Household

Information for Other Adults in Household

Minors (Under 18) in Household

Minors (Under 18) in Household

Financial Assistance Type

Monthly NET Household Income

In Archive