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2019 IQAP English Application

  • Complete all fields below. Only complete applications will be accepted.
  • Information provided will not be shared or used for any other purpose.
This question requires a valid email address.
Include dashes (XXX-XXX-XXXX)
Account number can be found on your utility bill or by calling 970-212-2900.
Include dash (XXXXXX-XXXXX)
6. Address: *This question is required.
Affidavit of Lawful Presence and Income Eligibility
My signature below certifies all information on this application is true and accurate, I can submit secure and verifiable documents showing I am lawfully present in the United States if requested, the total household income for this residence qualified for current or previous season LEAP benefits, and the homeowner, whether an occupant or a landlord, agrees to the program terms. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal law of Colorado as perjury in the second degree under C.R.S. 18-8-503, and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
8. Signature *This question is required.
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This question requires a valid date format of MM/DD/YYYY.
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