Form Dco 9495 – Fill Out and Use This PDF

ARKANSAS

HOME ENERGY ASSISTANCE PROGRAM

APPLICATION

If you need this material in a different format, such as large print,

CONTACT YOUR LOCAL COMMUNITY ACTION AGENCY

FOR AGENCY USE ONLY

Application Date

Application Time

a.m.

p.m.

Regular Assistance #

Crisis Intervention #

Disposition Time Limit

Interviewed By

Date

18 hrs.

48 hours

APPLICANT: All Sections of this form must be completed in order to determine your eligibility. Failure to complete this application and attach required documentation WILL delay the processing of your application.

YOU MUST APPLY AT THE LOCAL COMMUNITY ACTION AGENCY OFFICE WHICH SERVES THE COUNTY IN WHICH YOU LIVE.

Affordable Care Act (ACA) – The comprehensive health care reform law was enacted in March 2010. The law has 3 primary goals;

1)Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”)

that lower costs for households with incomes between 100% and 400% of the federal poverty levels; 2) Expand the Medicaid program to cover all adults, 19 – 64 years of age with income below 100% of the federal poverty level and 3) Support innovative

medical care delivery methods designed to lower the costs of health care generally.

FOR MORE INFORMATION GO TO HEALTHCARE.GOV OR CALL 1-800-318-2596

What utility do you need assistance with?

Which Low Income Home Energy Assistance Program (LIHEAP) are you applying for?

REGULAR ASSISTANCE – You do not need a disconnect notice.

CRISIS - You must have a disconnect notice or some other type of utility emergency. (If not, DO NOT check this box).

1. APPLICANT – PLEASE PUT YOUR NAME AND INFORMATION HERE

Last Name

First Name

Middle Name

Mailing Address

City

State

Zip Code

Street or Service Address (MUST BE LISTED)

City

State

Zip Code

Social Security Number

Phone Number

County of Residence

Sex

Date of Birth

Male

Female

Age

Do you have a Disability?

RACE:

White

Black

Spanish American/Hispanic

Oriental; Asian or Pacific Islander

Yes

No

American Indian or Alaskan Native

Other

Unknown

2. OTHER HOUSEHOLD MEMBERS – DO NOT INCLUDE YOURSELF

Please list the other persons living in your household but not yourself. Please complete all items.

(Please list additional members on a separate sheet).

Disabled

Name

Relationship to you

Date of Birth

Age

Race

Social Security Number

Yes No

1.

2.

3.

4.

5.

6.

7.

8.

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3. HOUSEHOLD INCOME

A. WORK INCOME - List anyone in your household who has work income (Includes self-employment, babysitting; etc.?)

1.

2.

3.

B. EMPLOYMENT – When were you or any member of your household age 18 or older last employed? NOTE: If you are no longer employed, or have

not worked in the past 6 - 12 months;	Please provide documentation that unemployment benefits are not being received.
Name		Where		When
1.
2.

C. NON-WORK INCOME – List anyone in your household who receives any of the following:

Social Security Income; (SSA) Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); Child Support; TEA; Alimony; Unemployment benefits; Worker’s Compensation; Veterans Benefits; Retirement Benefits; Housing Utility Assistance Payment; any other non-work

income (please describe):

			Gross Monthly	NON-WORK INCOME FROM	YOU MUST ATTACH
	Who Receives It?	How Often Paid			DOCUMENTATION FOR ALL
			Amount	(SSA, Retirement, etc.)
					NON-WORK INCOME.

1.

2.

3.

D. RESOURCES – Does anyone in your home have any of the following?

Resources

YES

NO

Amount

Where

Name(s) of Person

Cash on hand

Checking Account

Other Bank Accounts

CD

Other Resources (list)

CRISIS APPLICANTS ONLY: If your household is in need of crisis assistance, please indicate below:

My home energy utility has been disconnected.	Heating	Electricity
I have received notice that my home energy utility will be disconnected.			Heating	Electricity

My heating fuel is at or below 10% of the tank capacity and the fuel supplier will not deliver additional fuel without payment.

I have 3 week’s supply or less heating fuel (wood, coal, or other heating fuel not kept in a tank) and the fuel supplier will not deliver additional fuel without payment.

I have received an eviction notice which is partly due to my failure to pay my heating and/or electricity expenses to my landlord.

Other: I need assistance to pay a deposit to have my utility connected/reconnected.			Heating	Electricity	Other
Is your crisis situation life-threatening?	Yes	No If yes, please explain in detail.___________________________________________

_________________________________________________________________________________________________________________________

4. UTILITY/RENT INFORMATION

RENTERS ONLY - Is your energy cost included in your rent payment?

Yes No

If Yes, please attach a copy of your lease that indicates utilities are included in your rent and provide the name and phone number of your landlord ___________________________________________________________________________________________________________

Check (√) the primary or main fuel used to heat (not light) your residence CHECK ONLY ONE.

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5. HOME ENERGY SUPPLIER INFORMATION

Complete the following Section to show your Energy Suppliers (gas, electric, propane, etc.)

You must complete information on BOTH - GAS AND ELECTRIC AND include copies of EACH bill.

List Name of Gas/Propane/Wood Supplier: ___________________________ Acct. Number: ____________________________

Annual Propane Cost: $ _____________ (Previous heating cost 12 Months prior to the date of Application).

If your heating bill is not in your name, whose name is the account in? ________________________________________________

List Name of Electric Supplier: _____________________________________ Acct. Number: _____________________________

If your electric bill is not in your name, whose name is the account in? ________________________________________________

6. VERIFICATION OF IDENTITY

LIHEAP Policy requires applicants for HEAP to provide additional documents with each LIHEAP application. A READABLE COPY of one of the following VALID identifications must be provided.

1.	Arkansas Driver’s License	4.	Identification card for health benefits or other assistance
2.	Birth Certificate or similar document	5.	Voter registration card
3.	Work or school identification card	6.	Pay check stubs containing the name of the person

Any document that reasonably establishes the applicant or authorized representative’s identity will be accepted.

7. WEATHERIZATION SERVICES

Would you like to be referred for home Weatherization?	Yes	No
NOTE: This is not an application for Weatherization services.

8. APPLICANTS RIGHTS AND RESPONSIBILITIES

PLEASE BE SURE THAT YOU HAVE SIGNED YOUR NAME IN THE SPACE PROVIDED BELOW FOR SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE. FAILURE TO SIGN AND DATE THE APPLICATION WILL DELAY THE PROCESSING OF YOUR

LIHEAP APPLICATION.

I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in decision or delivery of services.

I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.

I authorize the contracted agency to release information relating to my application for LIHEAP to my Energy Supplier(s) to determine eligibility. I give permission to Arkansas Department of Human Services (DHS) to use information provided on this form for purposes of research, evaluation and analysis of the program.

I understand that my utility service provider will have no control over the data disclosed pursuant to this consent, and will not be responsible for monitoring or taking any steps to ensure that the LIHEAP office maintains the confidentiality of the data or uses the data as authorized by you.

I declare that all members of my household are legal residents of the United States.

I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political belief.

I understand that my signature on this application authorizes the agency to make any investigation concerning me or any household member and/or use a copy as a release of information for securing information needed to determine my eligibility for services.

I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding my circumstances, I must repay the cost of any assistance and may face penalty of criminal prosecution.

The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury.

________________________________________________________________		_______________________________________________
Signature of Applicant (must be same person listed in Section 1, page 1)	Date	Witness, if signed by mark	Date
or Authorized Representative
________________________________________________________________		_______________________________________________
Signature of Person Helping To Complete this Form	Date	Address of Witness	Date

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FOR AGENCY USE ONLY

*Verification must be attached.

Comments: _____________________________________________________________

_______________________________________________________________________

Date of Budget:

HH Size:

Worker:

B. DISPOSITION

Regular

Crisis

A. BUDGET:

1.

Confirmed that the household has not been approved

for LIHEAP in the current Subgrant Period.

1.

Income Month: (month prior to month of application)

2.

Approved

Denial

Withdrawal

_____________________

3.

Disposition Date: Regular ___________ CIP _________

2.

Total GROSS: (Earned Income)

4.

Benefit Amount: Regular ___________ CIP _________

$____________________

3.

NET (Earned Income) 80% Gross

C. PAYMENT

Regular

Crisis

1.

Payee

SUPPLIER: ______________________

$____________________

SUPPLIER: ______________________

APPLICANT:_____________________

4.

Unearned Income

2. Assistance provided (Crisis only)

Social Security

$____________________

Payment

Verbal Obligation

Specify:

___________________________________________

SSI

$____________________

___________________________________________

_______________________________

TEA

$____________________

Date: ____________ Time: _________

a.m.

p. m.

V A

$____________________

3.

Payment date: ____________ Check #: ____________

4.

Payment date: ____________ Check #: ____________

Other

$____________________

5.

Service Restored

6. Loss of Service Prevented

5.

Total Unearned Income $____________________

D. WEATHERIZATION REFERRAL

6.

Monthly Countable

Application was referred:

Yes

No

If no, check reason:

Income (3-5)

$____________________

1.

Already referred/assisted

2.

Referral Suspended

Applicant is an Agency Employee/Family Member?

Yes

No

Executive Directors’ Signature: ____________________________________________________________________________

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