GOVERNMENT OF THE VIRGIN ISLANDS OF THE UNITED STATES 
Department of Human Services 
 
 
Division of Family Assistance – Certification Unit  
 
Rev. 4/2022 
St. Croix Office 
Division of Family Assistance, Certification Unit 
4102 Mars Hill 
Frederiksted, VI 00840-3376 
(340) 772-7100 
certoffice.stx@dhs.vi.gov 
 
St. Thomas/St. John Office 
Division of Family Assistance, Certification Unit 
1303 Hospital Ground, Suite 1 
St. Thomas, VI  00802-6722 
(340) 774-0930 
certoffice.stt@dhs.vi.gov 
Energy Crisis Assistance Program 
 
 
 
Last Name          First Name             M.I.  
 
Date ______________________ 
 
Social Security Number: ___________________ 
 
Employer: _______________________________ 
 
Address: 
Home: ___________________________________ 
 
_________________________________________ 
 
Mailing: _________________________________ 
 
_________________________________________ 
Contact number(s): ________________________ 
Age: _____ Total Number in Household _______ 
 
Income: __________________ 
 
Total Household Income: ___________________ 
 
___ Copy of Income Attached 
 
Supplier Information 
Account Number: ______________________ 
 
Meter Number: ________________________ 
 
Meter Status __ Pending ___ Terminated 
 
Proposed termination Date _____________ 
Other Household Members: 
 
Name ____________Age ___ Relationship _____ 
 
Employer ________________ Income_________ 
 
 
Name ____________Age ___ Relationship _____ 
 
Employer _______________ Income__________ 
 
 
Name ____________Age ___ Relationship _____ 
 
Employer _______________ Income__________ 
 
 
Name ____________Age ___ Relationship _____ 
 
Employer _______________ Income__________ 
 
Direct Assistance/ Supportive Services 
 
____ General Assistance 
 
____ Food Stamps- Case Number _________ 
 
____ AFDC _______________ 
 
____ WIC ________________ 
 
____ Other, Specify ____________________