SELF DECLARATION OF PERMANENTLY PARKED NON-TRADITIONAL DWELLING (RECREATIONAL VEHICLE, FIFTH WHEEL, OR CAMPER)

Applicant’s Name: (please PRINT) Applicant’s Physical Address: Applicant’s Phone Number: __________________________ I declare that I reside in a permanently parked recreational vehicle, fifth wheel, or camper. I certify that I live in my permanently parked recreational vehicle, fifth wheel, or camper at the physical address listed on my application during the Wyoming LIEAP season to be eligible for LIEAP. I certify, under penalty of perjury, that the permanently parked recreational vehicle, fifth wheel, or camper I reside in meets the definition below to be considered a traditional dwelling. Traditional dwelling means a structure that provides a housing or residential environment that is affixed to a physical address. These structures include houses, apartments, townhomes, mobile homes, and permanently parked recreational vehicles, fifth wheels, and campers. Applicants must provide proof that the dwelling is affixed to a physical address denoting permanency. A P.O. Box address does not meet this burden of proof. Recreational vehicles, fifth wheels, and campers must be permanently parked in a location affixed to a verifiable physical address during the Wyoming LIEAP season to be eligible for LIEAP. By comparison the definition of a non-traditional dwelling: A non-traditional dwelling means a structure that provides housing that is not affixed to a permanent physical address and includes tents, lean-tos, or transportable cars, vans, buses, recreational vehicles, fifth wheels, or campers. LIEAP benefits will be subject to denial should it become known that a recreational vehicle, fifth wheel, or camper is no longer permanently parked at the physical address that was listed on the application. By my signature on this form, I swear/affirm that all information contained in the application and this form is true, correct, and complete, to the best of my ability, knowledge, and belief.

SIGNATURE:

LIEAP ID: {hhid}

DATE:

Revised 08/02/2017