Understanding the nuances and criteria of eligibility forms can be crucial for individuals seeking assistance through various programs. The LDSS-4992 form, associated with the Home Energy Assistance Program (HEAP), is a significant document for those needing aid to manage their home cooling expenses. With a specific focus on providing relief during warmer periods, this form plays a pivotal role for households that have already benefitted from HEAP in the current program year or those currently receiving Temporary Assistance (TA) or Supplemental Nutrition Assistance Program (SNAP) benefits. By leveraging information previously provided to these programs, the form simplifies the process of applying for cooling assistance, ensuring that individuals who are facing hardship due to heat, or have a household member with a heat-exacerbated medical condition, can find some respite. Importantly, the document underscores the necessity of honesty and accuracy in the application process, highlighting the potential for civil or criminal penalties in cases of falsification. Additionally, the form serves as a consent for investigations that verify the provided information and for the use of said data in referring applicants to weatherization or utility company low-income programs. Notably, while eligibility might be confirmed, the form also candidly states that receipt of benefits is contingent upon the availability of federal funds, showcasing the allocation challenges within assistance programs.
| Question | Answer |
|---|---|
| Form Name | Ldss 4992 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | weatherization, ineligible, misrepresentation, ldss 4992 revised 5 17 |
Date Received: _________________________
Home Energy Assistance Program (HEAP)
Home Energy Assistance Program
Cooling Assistance Application
(Short Form)
YOU MAY ONLY USE THIS APPLICATION IF:
Your household received a HEAP benefit during the current HEAP program year OR
You are currently receiving Temporary Assistance (TA) or Supplemental Nutrition Assistance Program (SNAP).
If you DID receive a HEAP benefit during the current HEAP program year, your eligibility for a cooling benefit will be based on the information used to determine your HEAP benefit and the information submitted on this form.
If you DID NOT receive a benefit during the current HEAP program year, BUT you are currently receiving TA or SNAP benefits, your eligibility for a cooling benefit will be based on the information in your TA or SNAP case and the information submitted on this form.
APPLICANT INFORMATION:
First Name
MI
Last Name
SSN (last 4 digits)
Street Address
Apt. No.
City
State
Zip
County
Daytime Phone Number
HOUSEHOLD INFORMATION: List everyone including yourself who currently lives in the same house.
Name |
SSN |
Date of Birth |
Blind or Disabled |
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NO |
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YES |
NO |
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3. |
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YES |
NO |
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4. |
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YES |
NO |
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5. |
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YES |
NO |
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6. |
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YES |
NO |
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Does your household contain an individual that has a medical condition that is worsened by extreme heat? If yes, please |
YES |
NO |
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provide a note from a physician, physician assistant or a nurse practitioner dated within the previous twelve months prior |
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to the month of application documenting this condition. |
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PLEASE READ, SIGN AND DATE
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 available weatherization assistance programs and to my utility company’s low income programs.
I understand that I may be eligible for a cooling benefit but may not receive a benefit if federal funds are not available for this component.
SIGNED: __________________________________________________________ |
DATE: ___________________ |
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FOR AGENCY USE ONLY |
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Received a current HEAP Program year benefit: |
Regular |
Emergency |
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Eligible |
Pended Start: ______________ |
End: ______________ |
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Ineligible because: |
No Vulnerable Household Member |
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Failed to Provide Information |
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Over Income Limit (Code 5) |
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Other |
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Comments: |
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Eligibility Determination Date: ____________ |
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Worker Signature: _________________________________ Date: ____________ |
Supervisors Initials: _______ Date: ________ |