Fl Miami Liheap Application PDF Details

Assistance for those facing difficulty in managing their home energy costs is crucial, and the Low Income Home Energy Assistance Program (LIHEAP) Application form serves as a vital gateway for Miami-Dade residents seeking aid. This application, offered by the Miami Dade Community Action Agency, is designed to provide financial assistance to eligible low-income households to help with their energy bills. The form requires applicants to furnish comprehensive details, including personal identification, home energy specifics, social security cards for all members living in the household, proof of income for the past month, and details about the household's demographics, such as the number of elderly persons, disabled persons, and young children. Additionally, it seeks information on the applicant's housing situation, including if the cost of home energy is included in their rent or if they live in government-subsidized housing. As a precaution against fraudulent claims, a statement emphasizing the truthfulness and completeness of the provided information is included, reminding applicants of the priorities in assistance allocation—households with the lowest income and greatest need. Furthermore, it outlines the process for crisis assistance and regular home energy assistance, including the agency's response times and the applicant's right to an appeals hearing if necessary. This thorough application process ensures that aid is directed to those who genuinely need it, providing not just financial relief but also a sense of security during challenging times.

QuestionAnswer
Form NameFl Miami Liheap Application
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmiami dade low energy program, liheap application pdf, liheap miami, printable liheap application dade county

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Miami Dade Community Action Agency

Low Income Home Energy Assistance Program

LIHEAP APPLICATION

For Office Use Only

Did you remember to attach COPIES of the following ?

[

]

Home Energy

[

] SS cards for all household members

[

]

Crisis

[

] Proof of income for all household members (past month)

[

]

Disaster Assistance

[

]

Copy of identification for applicant only

Stamp Date to the Right

[

]

Copy and original of most recent energy bill

PLEASE FILL OUT APPLICATION COMPLETELY

Your LIHEAP application is not a commitment that your bill will be paid. If eligible, a credit will be sent directly to the utility vendor. However:

You must continue to pay the amount owed on your bill.

1.Give the following information for yourself first and then each person living in your home. If more than six persons live in your home, list the additional persons, giving the same information on a separate sheet of paper and attach to this form.

Marital status: ________________ Place of birth: ________________

Ethnicity: ________________ Citizenship: _______________

 

 

 

 

 

 

 

 

 

 

 

Name

 

Date of

 

 

 

 

Relationship

Education

Source of

Monthly

First, Middle, Last

Social Security Number

Birth

Age

Sex

 

Race

to applicant

Completed

Income

Income

(Applicant Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 4

LIHEAP ASSISTANCE APPLICATION

Page 2 of 4

2.The address where you are living:

 

__________________________________________________________

___________, FL

__________

______________________

 

Street Number and Name, RFD, Apt. or Lot No.

 

City or Town

Zip Code

County

3.

Your mailing address, if different from above:

 

 

 

 

 

 

__________________________________________________________

___________, FL

__________

______________________

 

Street Number and Name, RFD, Apt. or Lot No.

 

City or Town

Zip Code

County

4.

Day time telephone number where you can be reached: (

) _________________________

(

) __________________________

5.If your monthly household income is less than $738 per month, explain how you pay for food, shelter, clothing, transportation and home utilities.

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

6.Complete the following for your household:

Number of elderly persons (65 or older)

#___________

Number of disabled persons

#___________

Number of children 5 years of age or younger

#___________

7.If you share your living or mailing address with others who are not part of your home, list their names:

_______________________________________; __________________________________; ___________________________________

8.If you or anyone in your home are not a U.S. citizen or an alien lawfully admitted for permanent residence, give the person’s name and alien status under the Immigration and Naturalization Act.

Name: _________________________________________________ Alien Status: _____________________________________________

9.

Are you or any member of your household a member of the Porch Creek Indian Tribe? Yes ______

No _______

LIHEAP ASSISTANCE APPLICATION

Page 3 of 4

10.Check the programs that anyone in your household is currently eligible for or receiving assistance from:

_____CSBG

_____Weatherization

_____TANF/WAGES

_____Food Stamps

_____None

11.If you or any member of your household has received energy assistance in the last 13 months, complete the information below:

_____________________________________________

_____________________________________

_____________________

Name of Agency

Type of help (elderly, crisis, emergency)

Date

12.Do any of the following situations currently apply to you? (Check appropriate box(es) below)

[

]

My electricity has been disconnected.

[

]

My current electric bill is delinquent.

[] I have a shut-off notice from the electric company.

[] None of the above currently apply to my household.

[

]

I have little or no propone, fuel oil or wood for heating.

[

]

I have a shut-off notice from my gas company.

[] My current natural gas bill is delinquent.

[] Other energy crisis-Describe:

________________________________________________________________________________________________________________

13.If your cost of home energy is included in your rent, give name and telephone number of your landlord. Attach a copy of a letter from the landlord confirming that your rent includes utilities.

Landlord: __________________________________________

Landlord’s Telephone Number ( ) ____________________________

14.If you live in government subsidized housing, Section 8 housing complex, a dormitory, nursing home, adult foster home, or any kind of group living facility, complete the following:

Name of place where you live: _____________________________________________________________________________________

__________________________________________________

________________,FL ________________

____________________

Street Number and Name, RFD, Apt. or Lot Number

City or Town

Zip Code

Country

LIHEAP ASSISTANCE APPLICATION

15.Provide the following information about the primary source of energy you use to heat your home. Give only one company.

 

 

 

Customer’s Name on the

Customer’s Account

Company’s Telephone

 

Energy Source

Company’s Name

Account

Number

Number

 

Electric

 

 

 

 

 

Natural Gas

 

 

 

 

 

Propane

 

 

 

 

 

Fuel Oil

 

 

 

 

 

Wood

 

 

 

 

16.

Provide the following information about the primary source of energy you use to cool your home.

 

 

 

 

Customer’s Name

Customer’s Account

Company’s Telephone

 

Energy Source

Company’s Name

on the Account

Number

Number

 

Air Conditioning

 

 

 

 

 

Fans

 

 

 

 

17.If not given above in questions 15 or 16 provide the following information about your electric company.

Energy Source

Company’s Name

Customer’s Name on the

Account

Customer’s Account

Number

Company’s Telephone

Number

18.Attach a copy of your current bills for all companies listed above in questions 15, 16, and 17.

FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need, i.e. those households in which the elderly, disabled, medical needy or children reside. I authorize the agency to obtain and release confidential information on may behalf and to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if I am applying for crisis assistance, the agency has 48 hours; 18 hours if my situation is life threatening, to approve or deny my application, and, if I’m applying for Home Energy Assistance, the agency has 45 days to approve or deny my application. I am aware that the agency has 45 days to make a payment to my fuel supplier on my behalf. I’m also aware that if I am approved or denied within the time allowed, or not approved for the correct amount, I have to right to an appeals hearing.

I have received a copy of the Miami Dade County Notice of Privacy Practices.

 

 

Return application to agency stamped below:

_______________________________________

________________

 

Applicant’s Signature

Date

 

______________________________________

________________

WEB APPLICATION

Eligibility Worker Signature

Date

 

_______________________________________

________________

 

Supervisor/ Edit Staff

Date

Page 4 of 4

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You should be requested for certain significant details so you can submit the The address where you are living, Street Number and Name RFD Apt or, FL City or Town Zip Code County, Your mailing address if different, Street Number and Name RFD Apt or, FL City or Town Zip Code County, Day time telephone number where, If your monthly household income, utilities, and Complete the following for your field.

printable liheap application dade county The address where you are living, Street Number and Name RFD Apt or, FL City or Town Zip Code County, Your mailing address if different, Street Number and Name RFD Apt or, FL City or Town Zip Code County, Day time telephone number where, If your monthly household income, utilities, and Complete the following for your blanks to fill out

The Complete the following for your, If you share your living or, If you or anyone in your home are, Name Alien Status, and Are you or any member of your field needs to be used to provide the rights or obligations of both sides.

stage 4 to completing printable liheap application dade county

Review the areas Check the programs that anyone in, CSBG, Weatherization, TANFWAGES, Food Stamps, None, If you or any member of your, Name of Agency, Type of help elderly crisis, Date, Do any of the following situations, My electricity has been, I have a shutoff notice from the, I have little or no propone fuel, and If your cost of home energy is and then fill them in.

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Related Resources

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    Florida's Low-Income Home Energy Assistance Program provides grants to local governments and non-profit agencies to assist eligible low-income Florida ... Florida's Low-Income Home Energy Assistance Program provides grants to local governments and non-profit agencies to assist eligible low-income Florida households in meeting the costs of home heating and cooling. The majority of the funds are used for utility payment assistance. The Low-Income Home Energy Assistance Program can assist customers pay their home energy expenses. The program has three categories of assistance: home energy assistance, crisis assistance, and weather related or supply shortage energy crisis assistance. Each category has unique requirements. To be eligible for this benefit program, you must be a resident of Florida and you must need financial assistance with home energy costs. A person who participates or has family members who participate in certain other benefit programs, such as SNAP, SSI, TANF, automatically meets the eligibility requirement. To be eligible, you must have an annual household income (before taxes) that is below the following amounts: Annual Household Income Limits (before taxes) Household Size* Maximum Income Level (Per Year) 1 $19,320 2 $26,130 3 $32,940 4 $39,750 5 $46,560 6 $53,370 7 $60,180 8 $66,990 *For households with more than eight people, add $6,810 per additional person. Always check with the appropriate managing agency to ensure the most accurate guidelines.

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