Ldss 3421 Form PDF Details

The LDSS-3421 form serves as a crucial gateway for individuals and families seeking support through the Home Energy Assistance Program (HEAP). This comprehensive application, revised in June 2011, mandates applicants to furnish detailed information spanning household composition, housing situation, utilities, income, and more. With a clear emphasis on ensuring accurate and exhaustive data collection, the form delineates sections that applicants must complete, ranging from personal identifiers to income sources, while also highlighting the importance of disclosing all household members and their respective financial contributions. Applicants are guided to specify their heating sources and utility payment responsibilities, which are critical for determining their eligibility and the type of assistance they may receive, whether it is for regular heating, equipment repair or replacement, or emergency situations. Additionally, the form explores the applicant's housing conditions, including ownership status and monthly rental or mortgage expenditures, to better understand the individual's or family's living arrangements. The documentation also touches on the authorized representative designation, allowing another person to undertake the application process on the applicant’s behalf. This representative can manage communications with the agency, submit required documentation, and receive notices about decisions and benefits. With its detailed inquiries into household income, the LDSS-3421 form meticulously gathers information on all potential income sources, ensuring a comprehensive evaluation of an applicant's financial state. Through this rigorous process, the form plays a pivotal role in facilitating access to essential home energy assistance for those in need, while also adhering to legal and procedural standards for application and eligibility determination.

QuestionAnswer
Form NameLdss 3421 Form
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other namesny heap application pdf, printable heap application, heap application pdf, ldss 3421 fillable

Form Preview Example

LDSS-3421 (Rev. 6/11)

2011-12

HOME ENERGY ASSISTANCE PROGRAM APPLICATION

Home Energy Assistance Program

ANSWER ALL QUESTIONS. DO NOT WRITE IN THE SHADED AREAS. PLEASE PRINT CLEARLY, AND SIGN THE FORM ON PAGE 5.

COMPLETE THE WHITE BOXES BELOW

AGENCY USE ONLY

DSS

OFA/ALTERNATE CERTIFIER

 

 

 

 

 

 

 

 

CONTACT THE AGENCY ABOVE IF YOU NEED HELP

 

 

 

 

 

 

 

DATE RECEIVED

 

 

 

 

 

 

DATE RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OFFICE

 

 

APPLICATION DATE

UNIT ID

 

 

WORKER ID

 

CASE

CASE NUMBER

 

 

 

REGISTRY NUMBER

 

 

VERS.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CASE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBER

 

 

 

HEAP

 

 

 

REGULAR HEATING EQPT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REUSE

 

 

 

INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY

OTHER_____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDICATOR

 

 

 

CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 1: HOUSEHOLD COMPOSITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST NAME

 

 

 

 

 

 

 

MI

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER NAMES BY WHICH I HAVE BEEN KNOWN ARE:

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APT. #

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

ZIP CODE

 

 

COUNTY

 

 

 

 

 

 

 

LENGTH OF TIME AT THIS ADDRESS?

 

YEARS__________

 

MONTHS__________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DAYTIME PHONE NUMBER WHERE I CAN BE REACHED (Area Code + Phone No.)

 

 

BEST TIME TO CALL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) IS:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

APT. #

CITY

 

 

 

 

 

 

 

COUNTY

 

 

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HAVE YOU EVER APPLIED FOR HEAP? YES

NO

IF YES, ENTER DATE OF MOST RECENT APPLICATION

 

 

 

 

 

 

 

 

 

LIST EVERYONE INCLUDING YOURSELF WHO CURRENTLY LIVES IN THE SAME DWELLING (If no one else, write NONE UNDER YOUR NAME):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITIZEN /

BLIND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SEX

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CD

LN

 

FIRST NAME

MI

 

 

 

LAST NAME

 

BIRTH

 

RELATION

 

 

SOCIAL SECURITY

 

 

NATIONAL

OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO.

DAY

YR.

M/F

 

TO ME

 

 

 

NUMBER

 

 

 

 

 

OR

DISABLED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUALIFIED ALIEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

02

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

1

04

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

1

05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

1

06

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL NUMBER IN HOUSEHOLD

If there are more members in your household, please attach a separate sheet of paper.

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET FOOD STAMP BENEFITS?

Yes No If yes, who? ___________________________________________ FS CASE NUMBER

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET TEMPORARY ASSISTANCE?

Yes No If yes, who? ___________________________________________ TA CASE NUMBER

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2. Once your current task is complete, take the next step – fill out all of these fields - APPLICANT INFORMATION FIRST NAME, LAST NAME, OTHER NAMES BY WHICH I HAVE BEEN, OTHER NAME, OTHER NAME, CURRENT STREET ADDRESS, APT, CITY, STATE, ZIP CODE, COUNTY, LENGTH OF TIME AT THIS ADDRESS, DAYTIME PHONE NUMBER WHERE I CAN, IF AN INTERVIEW IS NEEDED I WOULD, and Phone Interview In Person with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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3. This next segment is about YES NO, YES NO, YES NO, YES NO, YES NO, If there are more members in your, DO YOU OR DOES ANYONE LIVING AT, YES NO If yes who CASE NUMBER, DO YOU OR DOES ANYONE LIVING AT, and YES NO If yes who CASE NUMBER - type in each of these fields.

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4. This next section requires some additional information. Ensure you complete all the necessary fields - HOMEOWNER OTHER, Single Family House or Mobile Home, I live with someone else and share, Permanent hotelmotel Other living, RENTER, Private House Apartment or Mobile, SUBSIDIZED RENT, Private Subsidized Housing Public, Do you receive a HUD utility, MY MONTHLY RENT OR MORTGAGE, NONE, IF APPLICABLE THE NAME OF THE, DO YOU OR DOES ANYONE IN YOUR, YES, and SECTION HEAT AND UTILITY - to proceed further in your process!

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People frequently make some errors when filling in Single Family House or Mobile Home in this part. You need to revise whatever you type in right here.

5. And finally, the following final portion is what you will have to wrap up prior to submitting the PDF. The fields under consideration are the next: DO YOU PAY SEPARATELY FOR HEAT My, Natural Gas WoodWood Pellets, Fuel Oil Kerosene, Electric Propane or Bottle Gas, Coal or Corn Other, My fuel tank is, Individual Tank, Metered Tank, Is the heating bill in your name, YES, If No name on the bill, Relationship to you, Are you directly responsible to, YES, and Your heating companys name is.

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