Dear Applicant;

  Please read your application carefully and fill it out completely. Also make sure to include the following attachments with your mail-in application:

• Valid Government ID
• Copy of social security cards for all household members
• Most recent bill along with your current utility company print-out showing last 12 months of usage.
• Proof of gross income for anyone in the household ages 18 and over including minor children receiving SSA or SSI. (If no income, please fill out a statement of support showing who is providing support to the person with zero income). This is included in your application packet.
• Income: Wages - 

                       *   Weekly: You will need 4 consecutive paychecks showing gross income from the time of application back.

                        *  Bi-weekly: You will need 2 consecutive paychecks showing gross income from the time of application back

                        *  Monthly: You will need 1 consecutive paychecks showing gross income from the time of application back.

 

STEPS ON FILLING OUT AN ENERGY/CRISIS LIHEAP APPLICATION:


  1.    CHECK TYPE OF ASSISTANCE- ( REGULAR OR CRISIS)

• CRISIS APPLICATIONS UNLIKE REGULAR APPLICATIONS WILL NEED TO MEET A CRISIS GUIDELINE AND SHOULD BE PENDING DISCONNECTION - PLEASE MEET WITH YOUR COUNTY SERVICE CENTER MANAGER TO COMPLETE AN EMERGENCY APPLICATION DUE TO STRICT TIMELINES FOR PROCESSING.

  2.    CIRCLE (YES OR NO): REGARDING WHETHER YOU HAVE APPLIED FOR ASSISTANCE WITHIN THE CURRENT FISCAL YEAR AND ANSWER WHICH AGENCY.

  3.    FILL IN APPLICANT’S- NAME, TELEPHONE NUMBER, CURRENT ADDRESS, CITY, STATE, ZIP, COUNTY, AND MAILING ADDRESS IF DIFFERENT FROM UTILITY SERVICE ADDRESS.

  4.    LIST ALL HOUSEHOLD MEMBERS (PLEASE INCLUDE APPLICANT). AND INFORMATION CONCERNING EACH ONE.

  5.    CHECK FAMILY TYPE.

  6.    FILL IN ALL HOUSEHOLD DISABILITIES. ALSO CIRCLE (YES OR NO) ON REQUIRES LIFE SUPPORT EQUIPMENT.

• (IF YOU ARE CLAIMING YOUR DISABLED AND DO NOT RECEIVE A SSDA or SSI CHECK, WE NEED A DOCTOR’S STATEMENT STATING YOUR DISABILITY.                                                                  

  7.    LIST ALL HOUSEHOLD MEMBERS INCOME. (NAME, SOURCE, GROSS MONTHLY INCOME, AND EMPLOYER’S NAME & ADDRESS)

  8.    CHECK APPLICANT HOUSING TYPE.

  9.    CIRCLE THE SOURCE OF ENERGY IN WHICH YOU ARE WANTING HELP WITH.

10.    LEAVE HOME ENERGY COSTS AND PUBLIC HOUSING OVERAGE BLANK, WE WILL FILL THIS IN!!!

11.    IF YOU HAVE MORE THAN ONE UTILITY OR ENERGY COMPANY THAT NEEDS TO BE LISTED- PLEASE LIST THE ONE THAT YOU ARE WANTING HELP WITH FIRST!

12.    IF THE ACCOUNT NAME IS DIFFERENT THAN APPLICANT NAME- PLEASE LIST AND HIGHLIGHT THIS OR CIRCLE.

13.    CIRCLE (YES OR NO) IF THE ACCOUNT IS IN YOUR LANDLORDS NAME.

14.    READ APPLICANT CERTIFICATION SECTION AND CHECK WHETHER YOU (DO OR DO NOT) AGREE THAT THE INFORMATION IN YOUR APPLICATION CAN BE SHARED WITH OTHER AGENCIES.

15.    PLEASE SIGN AND DATE THE APPLICATION. (THE APPLICATION SHOULD NOT BE DATED UNTIL THE APPLICATION IS FULLY FILLED OUT AND HAS ALL REQUIRED DOCUMENTATION.)

16.    FILL OUT NUMBER OF HOUSEHOLD MEMBERS THAT ARE WITHIN THE AGE LIMITS IN THE GRAY BOX.