Form HSEA 6 at a glance
What it is: HSEA 6 is the Zero Income Statement, a form for an applicant whose household has little or no income.
Who signs: This form must be completed and signed by the applicant whose household has little or no income.
A filled-in Form HSEA 6 example: an applicant reports no income
How to fill out Form HSEA 6, box by box
CAO name and address, case identification, record name and date
Enter the CAO NAME AND ADDRESS and the CASE IDENTIFICATION: CO, RECORD NUMBER, CSLD and DIST.
Enter the RECORD NAME and the DATE.
Household income in the month before you applied for LIHEAP
Mark YES or NO. Has your household received any income in the month before you applied for LIHEAP?
If yes, please tell where it came from and how much you received.
Verification of any income received will be required. Types of verification may include proof of how much was given as a gift and when, details of loan agreements with repayment information from the lender, receipts for items sold, or other documentation as needed.
How your household is meeting its needs: Food, Shelter and Utility Service
Please tell how your household is meeting its needs for the following items:
Food, Shelter and Utility Service (electricity, heat, water, etc.).
Print Name, Signature and Date
Enter the Print Name and the Signature Date.
Common questions about Form HSEA 6
Who signs it?
This form must be completed and signed by the applicant whose household has little or no income.
Sources
[1] Form HSEA 6 (12/22), Zero Income Statement, Pennsylvania Department of Human Services (the Official source link on this page).