Emergency Lieap Wv Form – Fill Out and Use This PDF

Yes

No

Yes

No

Yes

No

If yes, what is the name?

First

Last

Yes

No

G. Do any of these apply to you today?

Already disconnected

Yes

No

Company name

Received a disconnect notice

Yes

No

Company name

Past due bill

Yes

No

Company name

Are you low on fuel/wood/coal (less than 3 days remaining)?

Yes

No

Are you out of fuel/wood/coal?

Yes

No

Non-working furnace/ boiler/heat system?

Yes

No

Yes

I certify that I have read or had read to me all statements

No

on this form and I do understand all questions. I further

certify that all information given is true and correct to the

best of my knowledge.

Yes

I understand I may request a hearing if I am not satisfied

No

with any decision of the local DHHR office in determining

my eligibility for LIEAP or the amount of benefits

approved, or if I feel that I have been discriminated

against because of race, color, national origin, sex, age,

religious or political beliefs, or because I am disabled, that

I may be represented by an attorney at a fair hearing but

that DHHR or any of its authorized representatives will not

pay for these legal services; and that LIEAP intake will

close without prior notice.

Yes

I understand that I may be asked to provide additional

No

information or verify any or all information entered on this

application form and that I will cooperate by providing

such information as required in determining my eligibility

for LIEAP; and I authorize DHHR to use and share all

such information with other agencies, organizations, or

entities to verify eligibility for LIEAP and the amount of

benefits.

Yes

I understand that the date of application is the date I

No

submit the completed form along with all required

verifications and information, and that missing information

may result in delay and/or denial of LIEAP benefits.

Yes

I give my consent for my heating and electric companies

No

to give data about my account and energy usage to the

West Virginia Department of Health and Human

Resources (DHHR), contractors for the Low Income

Energy Assistance Program (LIHEAP) and the

Weatherization Program.

Yes

I understand that if I knowingly provide false or fraudulent

No

information that is used in connection with the eligibility

determination for LIEAP, I may be subject, upon

conviction, to fines or imprisonment or both. I understand

I will be required to repay benefits received to which I am

not entitled and that my failure to repay such benefits

may result in loss of future LIEAP benefits.

Yes

I agree and authorize any bank, financial institution,

No

governmental agency or department, corporation,

business concern or person to furnish any information

which relates to my eligibility for and receipt of LIEAP to

DHHR or any of its authorized representatives and

understand DHHR may use or share such information to

verify my eligibility for and the amount of benefits.

Yes

I understand that I will be notified in writing within 30 days

No

from the date my completed application is received by

DHHR of the decision made on my application and that I

may request a hearing if I have not been notified within

30 days. If I receive a direct payment, I understand it

must be used to pay for the cost of primary home heating

and that a receipt which verifies my payment for this must

be submitted with my application for Emergency LIEAP. I

understand that if I am found eligible, I am entitled to only

one Regular LIEAP payment and one Emergency LIEAP

payment during the LIEAP season.

B. Was additional verification requested?

Yes

No

Indicate date application was considered complete:

Signature & Title of Worker from Other Agency

Date

FOR DHHR USE ONLY

A. Was application complete?

Yes

No

If no, what was missing?

B.

Date of Application:

Date of Decision:

C.

Date entered in RAPIDS:

Decision:

Approved

Denied

DHHR Worker’s Signature

Date