LIHEAP Application at a glance
What it is: LIHEAP Application of the Miami Dade Community Action Agency Low Income Home Energy Assistance Program.
Who signs: Sign on the Applicant's Signature line and enter the Date.
A filled-in LIHEAP Application example: a single applicant with a late electric bill
How to fill out LIHEAP Application, box by box
Attach copies of the following
Attach COPIES of SS cards for all household members, proof of income for all household members (past month), a copy of identification for applicant only, and a copy and original of most recent energy bill.
Household members
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.
For each person enter the Name, First, Middle, Last, Social Security Number, Date of Birth, Age, Sex, Race, Relationship to applicant, Education Completed, Source of Income and Monthly Income.
SELF is under Relationship to applicant for the first row.
Also enter Marital status, Place of birth, Ethnicity and Citizenship.
The address where you are living and the telephone number where you can be reached
Enter the address where you are living (3) and your mailing address, if different from the address where you are living (4): Street Number and Name, RFD, Apt. or Lot No., City or Town, Zip Code and County.
Enter the Day time telephone number where you can be reached. (5)
Monthly household income and your household
If your monthly household income is less than $738 per month, explain how you pay for food, shelter, clothing, transportation and home utilities (checked November 10, 2026).
Complete your household: Number of elderly persons (65 or older), Number of disabled persons and Number of children 5 years of age or younger. (7)
Programs and energy assistance
Check the programs that anyone in your household is currently eligible for or receiving assistance from: CSBG, Weatherization, TANF/WAGES, Food Stamps or None. (11)
If you or any member of your household has received energy assistance in the last 13 months, complete: Name of Agency, Type of help (elderly, crisis, emergency) and Date. (12)
Situations that apply to you
Check appropriate box(es) for the situations that currently apply to you: electricity disconnected, little or no propone, fuel oil or wood for heating, current electric bill delinquent, shut-off notice from your gas company, shut-off notice from the electric company, current natural gas bill delinquent, none currently apply to my household, or other energy crisis with a description. (13)
Primary energy sources
Enter the primary source of energy you use to heat your home: Company's Name, Customer's Name on the Account, Customer's Account Number and Company's Telephone Number. Give only one company.
Enter the primary source of energy you use to cool your home: Company's Name, Customer's Name on the Account, Customer's Account Number and Company's Telephone Number.
The signature
Sign on the Applicant's Signature line and enter the Date.
The information is, to the best of my knowledge, true and complete.
More rules for LIHEAP Application
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.
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. (9)
Are you or any member of your household a member of the Porch Creek Indian Tribe?
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. (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, Street Number and Name, RFD, Apt. or Lot Number, City or Town, Zip Code and Country.
If not given in questions 15 or 16, provide the following information about your electric company: Company's Name, Customer's Name on the Account, Customer's Account Number and Company's Telephone Number.
Attach a copy of your current bills for all companies listed in questions 15, 16, and 17.
After you have provided all the information requested, if you are applying for crisis assistance, the agency has 48 hours; 18 hours if your situation is life threatening, to approve or deny your application, and, if you are applying for Home Energy Assistance, the agency has 45 days to approve or deny your application.
Sources
[1] LIHEAP Application (edition not printed), Miami Dade Community Action Agency (the Official source link on this page).
