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Emergency Social Services Fuel Claim Form

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May be an image of ticket stub and text that says 'Dels ADH' (print): Please ompleted form and email EMERGENCY SOCIAL SERVICES FUEL CLAIM FORM (claimed weekly) (cheque MAILING ADDRESS: payable to) The 780-926-247 benefit will be paid directly to the vehicle owner. (address where cheque YOUR TREATY NO: 448- be mailed o) phone number: Cheque Evacuee Name (circle one): mailed Plate number pick Deposited (incl bank nfo) Tuesday Thursday Total Week May 7-13, May 14-20, 2023 May 21-27, 2023 May 28-June 3, 2023 June 4-10, 2023 June 11-17, 2023 June 2023 25-July 2023 Please here: Date you completed this form: Note: Incomplete information will not be processed.'

Due to our members being evacuated out of the High Level area, our resources to assist them are limited. The team has generated this Fuel Claim form. This claim form will be used to reimburse our members who are unable to utilize the fuel vouchers since the vouchers are only redeemable in Bushe River.

This form is for our Chateh residents who have been evacuated to Peace River and Manning. If you would like this to be direct deposited, please submit a direct deposit form with the Fuel Claim form to Trisha Metchooyeah.