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

LDSS-3421 (Rev. 6/11)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAGE 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2: HOUSING – CHECK () ONE BOX ONLY

 

 

 

 

 

 

 

HOMEOWNER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RENTER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single Family House or Mobile Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Private House, Apartment or Mobile Home

 

 

Multi-Family House; List Number of Units ____

 

 

 

Private Subsidized Housing

 

 

 

 

 

Co-op/Condo Owner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Housing Project or Senior Housing

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public Subsidized Housing

 

 

 

 

 

 

 

 

 

I live with someone else and share expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I pay for a room or room and board

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Permanent hotel/motel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other living situation _______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MY MONTHLY RENT OR MORTGAGE PAYMENT IS:

$ ________________________ NONE

 

 

 

 

 

 

 

IF APPLICABLE, THE NAME OF THE APARTMENT BUILDING OR HOUSING PROJECT I LIVE IN IS: ___________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DO YOU OR DOES ANYONE IN YOUR HOUSEHOLD RECEIVE A SENIOR CITIZEN RENT INCREASE EXEMPTION(SCRIE)?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3: HEAT AND UTILITY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YOU PAY FOR YOUR OWN HEAT,

 

 

 

OIL AND/OR KEROSENE HEATERS,

 

 

 

 

 

 

 

 

 

 

 

COMPLETE SECTION A BELOW:

 

 

 

 

 

 

COMPLETE SECTION B BELOW:

 

 

 

A. My main source of heat is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Do you have a written service contract?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

Yes, provide a copy

 

 

 

 

Fuel Oil

 

 

 

Natural Gas

Wood/Wood Pellets

 

IF YOU DO NOT PAY FOR YOUR OWN HEAT,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coal or Corn

 

 

 

Kerosene

Propane or Bottle Gas

 

 

 

 

 

 

COMPLETE SECTION C BELOW:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PSC Electric

 

 

 

Municipal Electric

 

Individual Tank

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. My household situation is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Metered Tank

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the heating bill in your name? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If No, the bill is in the name of: ___________________________

Both Heat and Utilities are included in the rent

 

 

 

Relationship to you: ________________________

 

 

 

 

 

 

 

 

 

 

 

 

Heat is included in rent but I pay for utilities (lights/cooking/hot

 

 

 

 

 

 

 

 

 

 

 

 

 

water). (Complete information below if checked)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you directly responsible to pay the bill? Yes No

Is the bill in your name? Yes No

 

 

 

 

 

 

 

Your heating account number is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If No, the bill is in the name of: __________________________

Please check if this is a landlord’s account number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship to you: ____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your heating company’s name is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you directly responsible to pay the bill?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your utility account number is:

 

 

 

 

 

 

 

STREET ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check if this is a landlord’s account number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY/TOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you also pay a utility company directly for your lights or

Your utility company’s name is: _____________________________

cooking or hot water?

Yes No

If yes, complete

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

information below

Is electric necessary to run the furnace?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your utility account number (if you have one) is:

 

 

 

 

 

 

 

 

 

 

 

 

Is electricity necessary to operate the thermostat in your

Please check if landlord’s account number

 

 

 

 

 

 

 

 

 

 

 

 

apartment?

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your utility company’s name is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is electric necessary to run the furnace?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is electricity necessary to operate the thermostat in your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

apartment? Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LDSS-3421 (Rev. 6/11)

PAGE 3

 

SECTION 4: HOUSEHOLD INCOME

REPORT ANY INCOME FOR ALL HOUSEHOLD MEMBERS. ALL AMOUNTS MUST BE REPORTED AS GROSS MONTHLY INCOME BEFORE ANY DEDUCTIONS. ATTACH ADDITIONAL SHEETS IF NECESSARY.

 

CHECK ONE (√)

TYPE OF INCOME

IF YES, GIVE AMOUNT

ADDITIONAL INFORMATION

WHO

 

 

 

 

(Gross Monthly Amount

 

RECEIVES?

 

 

 

 

before deductions)

 

 

 

 

 

SOCIAL SECURITY/including direct deposit

MONTHLY AMOUNT

Indicate amount you pay for :

 

 

 

 

 

Medicare

 

 

 

No Yes

 

$

Part B:

 

 

 

 

 

 

Medicare

 

 

 

 

 

 

Part D:

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY DISABILITY/including direct deposit

MONTHLY AMOUNT

Indicate amount you pay for :

 

 

 

 

 

Medicare

 

 

 

No Yes

 

$

Part B:

 

 

 

 

Medicare

 

 

 

 

 

 

 

 

 

 

 

 

Part D:

 

 

 

 

 

 

 

 

 

 

 

SUPPLEMENTAL SECURITY INCOME (SSI)

MONTHLY AMOUNT

 

 

 

 

No Yes

$

 

 

 

 

 

PENSION/RETIREMENT Private and/or government

MONTHLY AMOUNT

Source of Pension

 

 

 

No Yes

$

 

 

 

 

 

 

 

 

 

 

 

 

VETERAN’S BENEFITS

MONTHLY AMOUNT

 

 

 

 

No Yes

$

 

 

 

 

 

 

 

 

 

DISABILITY private or NYS

WEEKLY AMOUNT

Source

 

 

 

No Yes

$

 

 

 

 

 

CONTRIBUTION from someone outside the household

MONTHLY AMOUNT

Name of Contributor

 

 

 

No Yes

$

 

 

 

 

 

CHILD SUPPORT

WEEKLY AMOUNT

Source

 

 

 

No Yes

$

 

 

 

 

 

ALIMONY including payments for mortgage, utility bills,

MONTHLY AMOUNT

Source

 

 

 

No Yes

etc.

$

 

 

 

 

 

RENTAL INCOME apartment, garage, land, etc.

MONTHLY AMOUNT

Type of Rental

 

 

 

No Yes

$

 

 

 

 

 

ROOM/BOARD (received) etc.

MONTHLY AMOUNT

Name of Room/Boarder

 

 

 

No Yes

$

 

 

 

 

 

WORKER’S COMPENSATION

WEEKLY AMOUNT

 

 

 

 

No Yes

$

 

 

 

 

 

UNEMPLOYMENT BENEFITS

WEEKLY AMOUNT

Start Date:

 

 

 

No Yes

$

 

 

 

 

 

 

 

End Date:

 

 

 

 

 

 

 

 

 

 

No Yes

INTEREST from savings, checking, CDs, money market

 

 

 

 

 

accounts, etc.

ENTER INFORMATION ON PAGE 4

 

 

 

No Yes

DIVIDENDS from stocks, bonds, securities, etc.

 

 

 

 

 

 

 

 

 

WAGES

WEEKLY $

Employer

 

 

 

No Yes

 

BI-WEEKLY $

 

 

 

 

SUBMIT WAGE STUBS FOR THE PAST 4 WEEKS.

MONTHLY $

 

 

 

 

 

 

WEEKLY $

Employer

 

 

 

 

 

BI-WEEKLY $

 

 

 

 

 

Note: Gross Weekly amounts are multiplied by

MONTHLY $

 

 

 

 

 

4.3333 to calculate the monthly amount.

 

 

 

 

 

 

WEEKLY $

Employer

 

 

 

 

 

 

 

 

 

Gross Bi-Weekly amounts are multiplied by

BI-WEEKLY $

 

 

 

 

 

2.1666 to calculate the monthly amount.

MONTHLY $

 

 

 

 

 

 

WEEKLY $

Employer

 

 

 

 

 

BI-WEEKLY $

 

 

 

 

 

 

MONTHLY $

 

 

 

 

 

 

 

 

 

 

 

No Yes

IS THERE ANY OTHER INCOME FROM ANY OTHER

AMOUNT

Source

 

 

 

$

 

 

 

 

SOURCE? ATTACH EXPLANATION

 

 

 

 

 

 

 

 

 

 

 

 

 

SELF-EMPLOYMENT INCOME______________________ TYPE OF BUSINESS ______________________________

 

 

No Yes

If yes, you may choose to have your self- employment income calculated based on your filed federal tax return for the current year or

 

 

prior tax year if you have not yet filed for the current year, including all applicable schedules or based on the three (3) months prior to

 

 

 

your application. Please choose one method:

 

 

 

 

 

 

Filed Federal Tax Return

Past Three Months

 

 

PLEASE SIGN APPLICATION ON PAGE 5

LDSS-3421 (Rev. 6/11)

PAGE 4

IS THERE ANYONE IN YOUR HOUSEHOLD WHO DOES NOT HAVE ANY INCOME FROM ANY SOURCE? LIST ONLY HOUSEHOLD MEMBERS AGE 18 AND OLDER.

No Yes, list members with no income:

IS ANYONE IN YOUR HOUSEHOLD A FULL-TIME DEPENDENT HIGH SCHOOL OR COLLEGE STUDENT?

No Yes, Who ________________________________________

________________________________________

________________________________________

INTEREST & DIVIDEND INCOME

TYPE OF INCOME

IF YES, LIST AMOUNT

 

ADDITIONAL INFORMATION

 

RECEIVED FOR LAST 12

 

 

 

MONTHS

 

INTEREST from savings, checking, CDs, money market accounts, etc.

ANNUAL AMOUNT

Name of Bank

$

 

 

 

INTEREST from savings, checking, CDs, money market accounts, etc.

ANNUAL AMOUNT

Name of Bank

$

 

 

 

INTEREST from savings, checking, CDs, money market accounts, etc.

ANNUAL AMOUNT

Name of Bank

$

 

 

 

INTEREST from savings, checking, CDs, money market accounts, etc.

ANNUAL AMOUNT

Name of Bank

$

 

 

 

DIVIDENDS from stocks, bonds, securities, etc.

ANNUAL AMOUNT

Source of Dividends

$

 

 

 

DIVIDENDS from stocks, bonds, securities, etc.

ANNUAL AMOUNT

Source of Dividends

$

 

 

 

DIVIDENDS from stocks, bonds, securities, etc.

ANNUAL AMOUNT

Source of Dividends

$

 

 

 

DIVIDENDS from stocks, bonds, securities, etc.

ANNUAL AMOUNT

Source of Dividends

$

 

 

 

AUTHORIZED REPRESENTATIVE

You can authorize someone who knows your household circumstances to apply for HEAP benefits for you. This person is called your Authorized Representative. Your Authorized Representative may: complete and file your HEAP application, contact the agency and speak with your worker, have access to eligibility information in your case file, complete and sign all forms for you, provide documentation, appeal agency decisions, and receive forms and notices. The Authorized Representative designation will remain in effect for the current HEAP season unless revoked by you. Each HEAP season you will be asked if you want to designate an Authorized Representative.

Please check this box if you would like to authorize a HEAP Authorized Representative at this time.

Please check this box if you would like your Authorized Representative to get letters about your benefits.

You told us that you want someone to be your Authorized Representative for HEAP. Please provide us with the following information about the individual you want as your Authorized Representative.

Name of authorized representative:

Address and phone number:

PLEASE SIGN APPLICATION ON PAGE 5

LDSS-3421 (Rev 6/11)

PAGE 5

 

SECTION 5: IMPORTANT NOTICES

IMPORTANT NOTICE

YOU SHOULD BE AWARE THAT THERE IS LIMITED MONEY AVAILABLE FOR HEAP BENEFIT PAYMENTS. ONCE AVAILABLE MONEY IS USED UP, NO BENEFITS WILL BE ISSUED. THEREFORE, IT IS STRONGLY RECOMMENDED THAT YOU COMPLETE AND RETURN YOUR APPLICATION AS SOON AS POSSIBLE. BE AWARE THAT IN PAST YEARS THE PROGRAM HAS CLOSED DOWN AS EARLY AS MARCH 12.

LIFELINE – If you are applying for Lifeline the Office of Temporary and Disability Assistance may or may not release your name and address to your telephone service provider. Your telephone service provider may or may not use this information to enroll you in their Lifeline Service for a discounted telephone rate.

If you DO NOT want this information released, check this box .

You may contact your telephone service provider directly for enrollment in the discounted rate Lifeline Service.

PERSONAL PRIVACY LAW - NOTIFICATION TO CLIENTS

The State’s Personal Privacy Protection Law, which took effect September 1, 1984, states that we must tell you what the State will do with the information you give us about yourself and your family. We use the information to find out if you are eligible for the Home Energy Assistance Program and, if so, for how much. The section of the Law that gives us the right to collect the information about you is Section 21 of the Social Services Law. To make sure that you are getting all of the assistance you and your family are legally entitled to receive, we check with other sources to find out more about the information you have given us. For example:

We may check to find out if you or anyone in your household were working. We do this by sending your name and Social Security Number to the State Department of Taxation and Finance, and also to known employers, to tell us whether you worked and, if so, how much you made.

We may ask the State to check with the Unemployment Insurance Division to see if you or anyone in your household were getting unemployment benefits.

We may check with banks to make sure we know about any income you or anyone in your household may have received.

Besides using the information you give us in this way, the State also uses the information to prepare statistics about all the people receiving Home Energy Assistance. This information is used for program planning and management. The information is used for quality control by the State to make sure local districts are doing the best job they can. It is used to verify who your energy supplier is and to make certain payments to such vendors. Your failure to provide us with the information we need may prevent us from finding out if you are eligible for assistance and we may then have to deny your application. This information is kept by the Deputy Commissioner, Division of Information Technology (DoIT), Office of Temporary and Disability Assistance, 40 North Pearl Street, Albany, New York 12243-0001. Do not send your application to this address. If you or anyone in your household does not have a Social Security Number, a Social Security Number must be applied for at the U.S. Social Security Administration.

Read the Important Information Below

I swear and/or affirm that the information given on this application and subsequent phone interviews is true and correct. I realize that any false statements or other misrepresentation knowingly made by me in connection with this application and subsequent requests for HEAP assistance may result in my being found ineligible for the assistance paid to me or on my behalf. Additionally, any false statement or misrepresentation knowingly made by me for purposes of obtaining assistance under this program may result in an action against me which may subject me to civil and/or criminal penalties. I understand that by signing this Application/Certification, I consent to any investigation to verify or confirm the information I have given and any other investigation by any authorized government agency in connection with this and subsequent requests for Home Energy Assistance Program benefits for the current HEAP season. I also

consent to allow the information provided on this application to be used in referrals to the Weatherization Assistance Program and to my utility company’s low income programs.

TO GET HEAP ALL QUESTIONS MUST BE ANSWERED AND YOUR APPLICATION MUST BE SIGNED AND DATED BELOW.

SIGN HERE: X

DATE SIGNED

 

NAME OF PERSON, IF ANY, WHO ASSISTED YOU:

PHONE NUMBER:

 

 

LDSS-3421 (Rev. 6/11)PAGE 6

AGENCY USE ONLY

APPLICATION TYPE: Full Documentation

Simplified

 

 

 

Vendor

Account Number

 

Vendor Code

Vendor Relationship:

Current Bill/Vendor Statement

 

 

 

 

 

 

 

 

 

 

 

 

Collateral Contact

 

 

 

IDENTITY OF HOUSEHOLD MEMBERS

 

LN

 

HOUSEHOLD MEMBER’S NAME

 

 

DOCUMENTATION

01

 

 

 

 

 

 

 

02

 

 

 

 

 

 

 

03

 

 

 

 

 

 

 

04

 

 

 

 

 

 

 

05

 

 

 

 

 

 

 

06

 

 

 

 

 

 

 

IS ANYONE IN THE HOUSEHOLD VULNERABLE? Under the age of 6 Age 60 or older Permanently Disabled

Who__________________________________________ Documentation____________________________________________

RESIDENCE – CHECK TYPE OF DOCUMENTATION OBTAINED

Current Rent Receipt w/Name & Address Water, Sewage, or Tax Bill Mortgage Payment Book/Receipts w/Address Deed

Copy of Lease w/Address Utility Bill Homeowners Ins. Policy Other _______________________________________

INCOME DOCUMENTATION/CALCULATION

Categorically Eligible: TA FS Code A SSI

Comments, resolution activities, income calculation/documentation, verification of emergency for

REGULAR BENEFIT

expedited regular benefit, vendor contract, etc.

 

 

 

(EMERGENCY USE PART B)

Gross Bi-Weekly Income x 2.1666

 

 

 

 

SEPARATE HEAT (check one)

Gross Weekly Income x 4.3333

 

 

 

 

 

 

 

 

Oil

Kerosene

 

 

 

 

 

 

 

 

 

 

LP Gas

Natural Gas

 

 

 

 

 

Wood

Wood Pellets

 

 

 

 

 

Coal/Corn

PSC Electric

 

 

 

 

 

 

 

 

 

 

Municipal Electric

 

 

 

 

 

HEAT INCLUDED IN RENT

 

 

 

 

 

 

 

 

 

 

Payment to Household

 

 

 

 

 

Payment to Utility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL INCOME $

 

TIER I TIER II

Benefit $ ________________

Application compared to previous information

 

 

 

 

 

No prior application No Changes WMS Inquiry Changes verified

How:_______________________________________

Pended

START:

END:

 

 

APPROVED DENIED

 

 

 

 

 

 

 

 

 

 

 

CERTIFYING AGENCY

WORKER’S SIGNATURE/DATE

SUPERVISOR’S INITIALS/DATE

CONSENT TO WITHDRAW

I CONSENT TO WITHDRAW MY APPLICATION

SIGN HERE X_________________________________________________

I UNDERSTAND THAT I MAY REAPPLY FOR HEAP BENEFITS AT ANY TIME DURING THE PERIOD THAT HEAP APPLICATIONS ARE BEING ACCEPTED

LDSS-3421 (Rev. 6/11)

NEW YORK STATE HOME ENERGY ASSISTANCE PROGRAM

(HEAP)

APPLICATION INSTRUCTIONS

INSTRUCTIONS FOR COMPLETING THE APPLICATION:

Complete all non shaded areas and answer all questions.

List everyone who lives in your dwelling, even if they are not related to you or contributing financially to your household. You may be required to provide proof of identity for all household members.

Social Security numbers are required for all household members. If any member does not have a Social Security number but has applied for one, write the word “applied” in the Social Security Number box. If you leave this section blank for any

household member, your application will not be processed but will be pended for further information.

List ALL income for all household members. All amounts should be entered as gross income prior to any deductions. You may be required to provide proof of income. Eligibility will be based on your household’s gross monthly income for

the month of application.

Please enter the gross amount of your Social Security and the amounts you pay for Medicare Part B or D. Amounts for Medicare Parts B and D are excluded as income.

Only the interest or dividend portions of bank accounts, CDs, stocks, bonds or other investment income are used to calculate your income. Enter the amount received for the previous twelve (12) months.

Make sure to SIGN and date the application. The application must be signed by the person who has the heating bill in their name, or who pays the bill if it is in someone else’s name. If heat is included in the rent, the primary tenant must

complete and sign the application.

Motor Voter Registration

Please include the Motor Voter form with your application. Complete this form if you are not registered to vote and you want to register. This does not affect your HEAP eligibility or benefit amount.

WHAT WILL I NEED TO APPLY?

New applicants will need to include the following documentation along with your application:

Proof of each household member’s identity

A valid Social Security Number for each household member

Proof of residence

A fuel and/or utility bill if you pay for heat or proof that you pay rent which includes heat

Verification of income for all household members

Please see page 4 of the application instructions for specific types of acceptable documentation. In addition, new applicants will also need to complete an interview; and can choose whether you would like to conduct a phone interview or an in person interview. However, if you do choose a phone interview , please include a working phone number and the best time to contact you for a phone interview on Page 1 of your application.

WHERE TO APPLY:

You must apply in the county in which you currently reside. address stamped at the top of the application or can http://www.otda.ny.gov.

You can apply in person or mail in your application at the find other local certifiers by checking our website at:

LDSS-3421 (Rev. 6/11)

HOW DO I KNOW IF I AM ELIGIBLE?

You will receive a notice to let you know if your application has been approved or denied. If you are approved and you pay for heat, your payment will be sent to your heating fuel vendor. In some cases, your benefit will be paid to your electric company if heat is included in your rent. Your notice will tell you the amount of the benefit, how it will be paid, and how it was calculated. Vendors will not make deliveries until payment is received or until instructed to do so by the local Department of Social Services.

Regular HEAP benefits are intended to be a one-time supplement to your annual energy costs and are not intended to replace your personal payments. You should continue to pay your energy bills.

WHAT IF I HAVE AN EMERGENCY?

HEAP benefits can assist with the following emergencies:

You are out of fuel or have less than ¼ tank of oil, kerosene or propane, or less than a ten (10) day supply of other deliverable heating fuel.

Your natural gas or electric heat has been shut off or is scheduled to be shut off. Applicant owned heating equipment is not working.

If you have a heating emergency and have applied for, but have not received, your regular benefit, you should contact your local Department of Social Services. Whenever possible, regular HEAP benefits are used first to resolve an energy emergency.

DO NOT WAIT UNTIL YOU ARE OUT OF HEATING FUEL OR YOUR GAS/ELECTRIC SERVICE IS OFF TO REQUEST ASSISTANCE. IF YOUR UTILITY SERVICE IS TERMINATED, YOUR UTILITY COMPANY IS NOT REQUIRED TO RESTORE YOUR SERVICE EVEN IF YOU ARE ELIGIBLE FOR A HEAP BENEFIT.

All applications for heating equipment repair or replacement must be in person with full documentation.

Citizen /Alien Information:

In order to receive HEAP you must be a U.S.citizen, Qualified Alien, or U.S non-citizen national. For additional information on what constitutes a Qualified Alien or U.S. non-citizen national, please contact the New York State Office of Temporary and Disability Assistance hotline at 1-800-342-3009 or visit the OTDA website at http://www.otda.ny.gov.

Application Rights:

You have certain rights when filing your HEAP application. You have the right to be told if your application is approved or denied within thirty (30) business days of the date that the HEAP certifier receives your completed and signed application.

The processing time for applications will not begin until program opening even though you may have received an application prior to the program opening date as a part of our outreach effort. Please visit OTDA’s website at

http://www.otda.ny.gov or the OTDA hotline at 1-800-342-3009 for information regarding the date for program opening.

You have the right to request a conference and/or a fair hearing if it has been more than thirty (30) business days since the HEAP certifier received your signed and completed application (or it has been more than thirty business days since program opening if the certifier received your application prior to program opening and you have not been told of the eligibility decision).

If you would like a conference, you should ask for one as soon as possible. At the conference, if it is discovered that a wrong decision was made, or if because of information you provide, the decision is changed; corrective action will be taken.

If you would like a conference, please contact your local Department of Social Services Department listed above. This is only for requesting a conference. It is not how you ask for a fair hearing. If you ask for or have a conference, you are still entitled to a fair hearing.

LDSS-3421 (Rev. 6/11)

You can request a fair hearing from the New York State Office of Temporary and Disability Assistance by:

Calling, toll free:

1-800-342-3334 or by Writing to:

NYS Office of Temporary and Disability Assistance

Office of Administrative Hearings

P.O. Box 1930

Albany, NY 12201-1930.

If you request a fair hearing, NYS will send you a notice of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, friend, or other person, or to represent yourself. At the hearing, your attorney or other representative will have the opportunity to present written and oral evidence, as well as the opportunity to question any persons who appear at the hearing. Also, you have the right to bring witnesses to speak in your favor. You should bring to the hearing any documents that may be helpful in presenting your case.

If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid society or

other legal advocate group. You may locate the nearest Legal Aid society or advocate group by checking the yellow pages under “lawyers”.

You have the right to review your case record. Upon your request, you have the right to free copies of documents that your local Department of Social Services presents into evidence at the fair hearing. Also, upon request, you have the right to free copies of other documents from your case record that you need for your fair hearing. To request such documents or to find out how you may review your case record, contact your local Department of Social Services listed above.

Si necesita alguien que hable español, comuníquese con la línea directa de NYS OTDA al 1-800-342-3009.

Telephone Lifeline Program:

If you qualify to receive HEAP, you also qualify for low cost local telephone service under the Lifeline Program. You can get basic local service for as low as $1.00 per month, plus per call charges and taxes. We will share your name with Verizon so that you can be automatically enrolled in Lifeline, unless you mark the box on the application to decline the release of your information. You may also contact your telephone company to receive a Lifeline application, or for more information on the Lifeline Program. This does not affect your HEAP eligibility or benefit amount.

OTHER PROGRAMS YOU MAY BE ELIGIBLE FOR:

WEATHERIZATION ASSISTANCE

You may also be eligible for weatherization assistance. A list of contacts can be found at: http://nysdhcr.gov/Programs/WeatherizationAssistance/. Your signature on the HEAP application allows a referral to be made to the weatherization assistance program on your behalf.

UTILITY LOW INCOME PROGRAM

You may also be eligible to enroll in you utility company’s low income program. Your signature on the HEAP application allows a referral to be made to your utility company on your behalf.

MY BENEFITS

Additional information about HEAP and other human services programs can be found at MY BENEFITS. You can also conduct a self-screening for eligibility for HEAP and other programs. Please go to https://www.mybenefits.ny.gov for more information.

LDSS-3421 (Rev. 6/11)

TYPES OF ACCEPTABLE DOCUMENTATION

RESIDENCE (Where you now live)

 

Current rent receipt with name and address of tenant and

Utility bill

landlord or lease with name and address

Mortgage payment books/receipts with address

Water, sewage, or tax bill

Homeowners insurance policy

Deed

 

IDENTITY

You must provide one or more of the following for each person in your household:

Birth certificate

Social Security card

Baptismal certificate

Driver’s license

School records

Marriage certificate

SOCIAL SECURITY NUMBER

You must provide a valid Social Security Number for each member of your household. If a Social Security Number cannot be validated by the Social Security Administration, you will be required to provide proof of that Social Security Number. To prove a valid Social Security Number, please provide:

Social Security card OR Official correspondence from Social Security Administration

VULNERABILITY

You must provide one of the following for proof of vulnerability for a vulnerable member of your household (children under

6 years of age, adults 60 years of age or older, or anyone with a disability):

Birth certificate

Passport

Copy of benefit check

Driver’s license

Baptismal certificate with date of birth

Written statement of eligibility for benefits

Award letter

 

HEATING SITUATION

If you pay a fuel or utility bill, bring a copy of your most recent fuel/utility bill or a statement from your vendor.

If you do not pay for heat, bring a current rent receipt with name and address of tenant and landlord, lease with name and address, or statement from your landlord that indicates heat is included in your rent.

INCOME

Pay stubs for the most recent four (4) weeks

COPY OF MOST RECENT CHECK OR AWARD LETTER

If self-employed, business records for the most recent

FOR THE FOLLOWING:

three (3) months or your filed federal tax return for the current

Social Security/Supplemental Security Income (SSI)

year, including all applicable schedules or prior tax year if

Veteran’s Benefits

you have not yet filed for the current year

Pensions

Rental income receipts for previous 12 months

Worker’s Compensation/Disability

Child support or alimony checks

Verification of Unemployment Insurance Benefit amount

Bankbook/dividend or interest statement

Educational Grants/Loans

Statement from roomer/boarder

 

RESOURCES (For emergency benefit applications only)

 

Cash Checking and/or savings account balances

IRA accounts

Stocks/bonds

Lump sums from sale of property or insurance

Time Deposit Certificates

settlements.

Applications for Heating Equipment Repair and Replacement require additional documentation. If you are applying for this component, you will be given a separate list of documentation you need to provide.

NYS Agency-Based Voter Registration Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Important!

 

 

 

 

 

“If you are not registered to vote where you live now,

 

 

 

 

 

 

 

 

 

 

would you like to apply to register here today?”

 

 

 

 

 

Applying to register or declining to register to vote will

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

not affect the amount of assistance that you will be

 

 

 

 

YES

 

(If you check yes, please complete VOTER REGISTRATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

provided by this agency.

 

 

 

 

 

 

 

 

APPLICATION at bottom of page)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO because I choose not to register OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am already registered at my current address OR

 

 

 

 

 

If you would like help filling out

the voter registration application

 

 

I asked for and received a mail registration form.

 

 

 

 

 

form, we will help you. The decision whether to seek or accept help

 

 

 

 

 

 

 

is yours. You may fill out the application form in private.

 

 

If you do not check any box, you will be considered to have

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

decided not to register to vote at this time.

 

 

 

 

 

 

 

 

Información en español: si le interesa obtener este formulario en

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

español, llame al 1-800-367-8683

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____/______/______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Signature)

 

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please Print Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOTER REGISTRATION APPLICATION (instructions on back)

NVRA-05 (01/2011)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes, I need an application for an Absentee Ballot

 

Please print or type in blue or black ink Yes, I would like to be an Election Day worker

 

 

 

 

 

Are you a U. S. citizen?

 

 

 

 

 

 

 

Will you be 18 years old on or before election day?

 

For Board use only!

1

 

 

Yes

No

 

 

 

 

 

2

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you answered NO, do not complete this form unless

 

 

 

 

 

 

 

 

 

If you answered NO, do not complete this form.

 

 

you will be 18 by the end of the year.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

Last Name

 

 

 

 

 

First Name

 

 

 

 

 

 

 

 

Middle Initial

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

Address where you live (do not give P.O. address)

 

Apt. No.

City/Town/Village

Zip Code

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address where you get your mail (if different from above)

 

P.O. Box, star route, etc.

 

Post Office

 

Zip Code

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

 

Date of Birth

 

 

 

7

Sex (circle)

8

 

Home Tel. Number (optional)

 

 

ID NumberCheck the applicable box and provide your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

number:

 

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

 

 

 

 

 

 

 

 

New York DMV number __ __ __ __ __ __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The last year you voted

 

Your Address was (give house number, street and city)

 

9

If you do not have a New York DMV number, please

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

provide:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last four digits of your

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In county/state

 

 

 

Under the Name (if different from your name now)

 

 

Social Security Number __ __

__ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I do not have a New York Driver’s license number

 

 

 

 

 

Choose a party -- Check one box only

 

 

AFFIDAVIT: I swear or affirm that

 

 

 

 

 

 

 

 

 

 

Democratic Party

 

 

 

 

 

 

 

 

 

I am a citizen of the United States.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I will have lived in the county, city or village for at least 30 days before the election.

 

 

 

 

 

Republican Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I will meet all requirements to register to vote in New York State.

 

 

 

 

 

 

 

Conservative Party

 

 

 

 

 

 

 

 

 

This is my signature or mark on the line below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The above information is true, I understand that if it is not true, I can be convicted and

11

 

Working Families Party

 

 

 

 

 

 

12

 

 

 

 

 

 

 

 

 

fined up to $5,000 and/or jailed for up to four years.

 

 

 

 

 

 

 

 

Independence Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Green Party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (write in)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I do not wish to enroll in a party

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Signature or Mark in Ink)

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Optional) Register to donate your organs and tissues

Last Name

First Name

Middle Initial

 

 

 

Suffix

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

Apt Number

 

 

 

 

Zip Code

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date

 

 

 

 

 

Sex □ M

 

□ F

Eye Color

 

 

 

 

 

Height

 

Ft.

 

In.

 

 

 

 

 

 

 

By signing below, you certify that you are:

18 years of age or older

Consent to donate all of your organs and tissues for transplantation, research, or both;

Authorizing the Board of Elections to provide your name and identifying information to DOH for enrollment in the Registry;

And authorizing DOH to allow access to this information to federally regulated organ procurement organizations and NYS-licensed tissue and eye banks and hospitals upon your death.

Sign

Date

Qualifications for Registration

You Can Use This Form To: register to vote in New York State;

change your name and/or address, if there is a change since you last voted;

enroll in a political party or change your enrollment. To Register You Must:

be a U.S. citizen;

be 18 years old by December 31 of the year in which you file this form (note: You must be 18 years old by the date of the general, primary, or other election in which you want to vote.);

be a resident of the County, or of the City of New York at least 30 days before an election;

not be in jail or on parole for a felony conviction; and not claim the right to vote elsewhere.

Important!

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with:

New York State Board of Elections, 40 Steuben Street,

Albany, New York 12207-2109

Telephone: 1-800-469-6872;

TDD/TTY users contact the New York State Relay at 711;

or visit our web site - www.elections.state.ny.us

Your decision to register will remain confidential and will be used only for voter registration purposes. Anyone not choosing to register to vote and/or information regarding the office to which the application was submitted will remain confidential, to be used only for voter regis- tration purposes.

Verifying your identity

We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID number), or the last four digits of your social security number, which you will fill in Box 9.

If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement, pay- check, government check or some other government document that shows your name and address. You may include a copy of one of those types of ID with this form.

If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.

To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.

Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?). If you voted before under a different name, put down that name. If not, write “Same”.

Box 11: Check one box only. To vote in a primary election, you must be enrolled in one of these listed parties Except the Independence Party, which permits non-enrolled voters to participate in certain primary elections.

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