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Chillax Care Program Application

If you're facing financial hardship and need help with an essential HVAC repair, you may qualify for assistance. Fill out our short online application below.

 

Requests are reviewed based on need, safety, and available funds.
Approval for assistance is not guaranteed.

Basic Contact Information

Household Information

Are there vulnerable members in your household? (i.e. elderly, young children, or anyone with health conditions)
Yes
No

System Information

Is your HVAC system currently working at all?
Yes
No
Which of the following best describes the current problem? (select all that apply)

Repair Coverage Needs

We want to help in the way that works best for you:
I need the full repair cost covered by the Chillax Care Program
I’m able to cover part of the parts/equipment cost and need assistance with the remainder

If your application is accepted, please be prepared to show one of the following items as proof of need:

  • Proof of income-based assistance (SNAP, SSI, Medicaid, WIC, etc.)

  • Recent utility shutoff notice or overdue bill

  • Letter from social worker, community organization, or pastor

  • Short personal statement describing current financial hardship


We will review your documentation to verify eligibility, but we will not make copies or keep these documents. Please do not email us copies. Your privacy is important to us, and we want to ensure your personal information remains protected.

Optional Release for Storytelling

No personal details will be shared without your consent. Declining to share will not impact your eligibility for assistance.

By submitting this application:

  • I certify that all information provided in this application is true, complete, and accurate to the best of my knowledge.

  • I am applying for assistance in good faith and understand that providing false information may disqualify me from the program.

  • I am prepared to show proof of need to the technician before repairs are performed.

  • I agree to pay an $80 diagnostic fee at the time of service to help cover gas, insurance, and operating costs.

  • I understand that community donations may be used to cover the cost of parts and materials, while Chillax Heating and Air Conditioning, LLC will donate the labor.

  • I understand that this program is intended for repairs and part replacements only, and does not cover full system installations or new system purchases.

  • I understand that assistance is based on fund availability and is not guaranteed.

  • I give permission for Chillax to contact me regarding this application.

By typing my name below, I certify that the information in this application is true and complete, and I agree to the terms outlined in this application.

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