Lieheap Program Form – Fill Out and Use This PDF

The Low Income Home Energy Assistance Program (LIHEAP) Walk-In Application is crafted to aid households bearing the weight of heating or cooling expenses, notably those with direct responsibility for these costs. Designed with inclusivity at its core, the application accommodates households with at least one member being a U.S. citizen or possessing lawful immigration status, ensuring a wide array of individuals can seek assistance. Interested parties are encouraged to complete this form and return it to their local OKDHS office to potentially alleviate their energy-related financial burdens. Click the button below to initiate the application process.

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Lieheap Program Form PDF Details

The Low Income Home Energy Assistance Program (LIHEAP) offers critical support for families struggling with utility bills, providing a lifeline during both the sweltering summers and the chilling winters. This program, tailored for families and individuals with low income, ensures that the basic necessity of heating or cooling one's home is not a luxury but a guarantee. With a comprehensive application process, highlighted by the LIHEAP-1B form, applicants are required to detail their household composition, income, resources, and expenditures, ensuring a fair assessment of their needs. This form not only captures the quintessential data pertaining to the household's financial landscape but also delineates the applicant's responsibilities, including reporting any changes in citizenship status or address, thus safeguarding the integrity of the program. Submission to the Oklahoma Department of Human Services (OKDHS), the entity responsible for administering LIHEAP locally, initiates a process designed to offer assistance efficiently and equitably. Notably, the program's inclusivity is evident through its eligibility criteria, catering to U.S. citizens and lawful immigrants alike and offering a special nod to Native American households with the option to apply through their tribe or OKDHS, ensuring that no one in need is left in the cold.

Question	Answer
Form Name	Lieheap Program Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	apply for liheap oklahoma, liheap oklahoma, printable liheap application, liheap application online

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*LIHEAP1B *

Date:

Case name:

Case number:

County number:

Supervisor/worker number: /

Low Income Home Energy Assistance Program (LIHEAP)

Walk-In Application

FOR OKDHS USE ONLY.

Payee number Application date Certification date

Shelter code

Categorical code

Submit only one application per household.

If your household is directly responsible for heating or cooling costs, you may apply for help in paying this expense by completing this application, and returning it to your local OKDHS office. At least one household member must be a U.S. citizen or an alien in lawful immigration status for your household to be eligible. If you or anyone in the household is Native American, you may apply either with OKDHS or with your tribe, but you cannot receive heating or cooling assistance from both.

Did anyone in your household apply for or receive Tribal LIHEAP assistance this year? Yes No

I. Tell us about everyone who lives in the home starting with the adult head of household. This person will be the payee. You must check yes or no in the U.S. citizen block and fill in the Social Security number for each person who wants benefits. If there are more than six persons in your household, attach another sheet of paper showing their information.

Person 1. Name of adult head of household

Sex

Date of birth

U.S. citizen

Alien registration number

Social Security number

Yes

Race - check all that apply

Are you Hispanic or

Black or African American

White

Latino?

Native Hawaiian or other Pacific Islander

Asian

Yes

American Indian or Alaskan native

Tribe:

Mailing address, street or P.O. Box

City

State

Zip

Street address or directions to your home, if different than mailing address

Phone number where you can be reached

Email address

Form 08LH002E (LIHEAP-1-B) revised 7-1-2011 may continue on next page, page 1 of 5

				Sex			Date of birth
				M		F

U.S. citizen		Alien registration number		Social Security number
Yes	No

Race - check all that apply					Are you Hispanic or
Black or African American			White		Latino?
Native Hawaiian or other Pacific Islander			Asian				Yes	No
American Indian or Alaskan native			Tribe:


Person 3. Name				Sex			Date of birth
				M		F
U.S. citizen		Alien registration number		Social Security number
Yes	No

Race - check all that apply					Are you Hispanic or
Black or African American			White		Latino?
Native Hawaiian or other Pacific Islander			Asian				Yes	No
American Indian or Alaskan native			Tribe:


Person 4. Name				Sex			Date of birth
				M		F

U.S. citizen		Alien registration number		Social Security number
Yes	No

Race - check all that apply					Are you Hispanic or
Black or African American			White		Latino?
Native Hawaiian or other Pacific Islander			Asian				Yes	No
American Indian or Alaskan native			Tribe:


Person 5. Name				Sex			Date of birth
				M		F
U.S. citizen		Alien registration number		Social Security number
Yes	No
Race - check all that apply					Are you Hispanic or
Black or African American			White		Latino?
Native Hawaiian or other Pacific Islander			Asian				Yes	No
American Indian or Alaskan native			Tribe:


Person 6. Name				Sex			Date of birth
				M		F

U.S. citizen		Alien registration number		Social Security number
Yes	No

Race - check all that apply						Are you Hispanic
Black or African American			White			or Latino?
Native Hawaiian or other Pacific Islander			Asian				Yes	No
American Indian or Alaskan native			Tribe:

Form 08LH002E (LIHEAP-1-B) revised 7-1-2011 may continue on next page, page 2 of 5

II. Tell us about your income and resources.

Total household gross income from employment (before deductions):	$
Total household income from sources other than employment:	$
Do you receive financial help from any source to pay for your housing
and heating or cooling cost?
If yes, who?

Yes

Total cash assets, including cash on hand, checking or savings accounts, certificates of deposit (CDs), and stocks or bonds:

III. Tell us about your expenses.

Housing is:	rented	owned/buying	room only
Amount of rent you pay: $
If renting or rooming, does your rent include your heating or cooling bill?				Yes	No

You may be eligible for a medical expense deduction for household members who are disabled or age 60 or older. These costs could be doctor or hospital bills, medicine, transportation, health insurance premiums, or other medical services.

Please list monthly medical expenses here.

Name

Type of expense

Monthly expense

	$

	$

	$

Does anyone in your household PAY court ordered child support?	Yes	No
If yes, please fill out the information below:

Who pays support?

How much?

How often?

Who gets support?

Phone number

IV. Tell us about your primary source of heating or cooling fuel.

Only your utility bill for the current season will be considered for payment. Be sure to list the name of the company that bills you, because OKDHS will pay directly to the utility company.

Natural gas or electricity - Attach most recent bill or copy of bill.

Company name

Account number

Account name, as shown on your bill

If the account is not in your name, explain

Address where gas or electric meter is located

Form 08LH002E (LIHEAP-1-B) revised 7-1-2011 may continue on next page, page 3 of 5

Propane or butane. I want my (check one): propane butane delivered by:

Company or supplier name

Mailing address of supplier

Address where the fuel tank is located or fuel is delivered

Firewood, coal, oil, or kerosene.

For heating fuel, I use (check one):

firewood

coal

oil

kerosene

Do you presently have a shut-off notice or is your fuel supplier refusing to deliver?

Yes

V. Things you should know.

You must contact your local OKDHS office to make an application for energy assistance.

If you move after submitting your application, even if the same company provides your heating or cooling fuel, you must report your new account number to the local OKDHS office.

If you have not received a notice of approval or denial within 10 days of submitting this application and providing needed proof, contact the local OKDHS office.

You have the right to appeal any delay in decision and any action of the local OKDHS office, which you consider improper by requesting a fair hearing. You or your representative may have access to records relevant to the appeals process. Requests for a fair hearing may be made at your local OKDHS office.

I certify under penalty of perjury that I have truthfully reported the citizenship status of every person in my household. I understand I must advise OKDHS if anyone in my household is not in lawful immigration status.

If OKDHS approves my household for benefits and it is later determined I made a false claim of United States citizenship or lawful immigration status for anyone in my household, a complaint will be filed by OKDHS with the U.S. Attorney, and I may be subject to criminal prosecution.

I hereby authorize OKDHS to make any necessary investigation of my household's financial situation and other conditions relating to eligibility, including, but not limited to, examination of my account with any public utility provider. I have been informed that any person who knowingly, willfully, and fraudulently provides false information for the purpose of obtaining benefits that he or she is ineligible to receive may be subject to prosecution to the fullest extent of the appropriate state or federal statute.

Signature

Date

Phone

Witness, if you sign with an X:

Signature

Form 08LH002E (LIHEAP-1-B) revised 7-1-2011 may continue on next page, page 4 of 5

OKDHS has assured compliance with Department of Health and Human Services (DHHS) Regulations, Title 45, Code of Federal Regulations, Part 80 and Part 84. These laws and regulations prohibit excluding from participation in, denying the benefits of, or subjecting to discrimination under any program or activity receiving federal financial assistance any person on the grounds of race, color, national origin or any qualified person on the basis of disability. Written complaints of noncompliance with either law should be made to the OKDHS Director, Box 25352, Oklahoma City, Oklahoma, 73125, or to the DHHS Secretary, Washington, D.C., or both.

FOR OKDHS USE ONLY. Income computation:

Gross earned income		$		MINUS
$240 work related expense for each wage earner $				PLUS
Gross unearned income		$		MINUS
Legally binding child support, if eligible		$		MINUS
Medical expenses, if eligible		$		EQUALS
Countable income of		$
Household size: adults	children		. Eligible amount: $

60 or older

disabled

2 years old or under

3 to 5 years old

Worker's signature	User identification no.	Supervisor/	Date
		worker no.

Form 08LH002E (LIHEAP-1-B) revised 7-1-2011 may continue on next page, page 5 of 5

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Lieheap Program Form – Fill Out and Use This PDF

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