Spectrum LIHEAP Application Request Form
First Name *
Last Name *
Main Phone *
Enter only numbers, no dashes, parenthesis, spaces, or dots. Example: 5105551234
Type of Main Phone *
Secondary Phone
Enter only numbers, no dashes, parenthesis, spaces, or dots. Example: 5105551234
Type of Secondary Phone
Email *
Street Address *
City *
Zip Code *
Are you interested in our Weatherization Program?
More information on the Weatherization Program on our website at https://spectrumcs.org/energy-services/weatherization
Clear selection
Reason for Mailing *
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