LIHEAP Application - Northcentral Arkansas Development Council

ARKANSAS LIHEAP
Application for Utility Bill Assistance

Complete all sections and attach requested documentation; failure to do so will delay eligibility determination.

Proof of identity. May include one of the following: Valid driver’s license or other government issued ID; health insurance card or employment ID; or birth certiﬁcate, if under age one (1). Invalid Input

Social Security Number Social Security Card must be verified for new applicants Invalid Input

Proof of ALL income listed on/with this application Invalid Input

Copies of ALL heating and cooling bills Invalid Input

Copy of lease agreement, if utilities are included in rent Invalid Input

County of Residence(*)

Please select your county.

What bill do you need assistance with?

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APPLICANT - PLEASE PUT YOUR NAME AND INFORMATION HERE

attach a copy of ID(e.g. driver's license) and Social Security Card

Last Name(*)

Please enter your last name.

First Name(*)

Please enter your first name.

Middle Name

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Physical Street Address

Please enter your mailing address.

City

Please enter your city.

State

Please select your state.

Zip Code

Please enter your ZIP code.

Is your mailing address the same as your physical address?

YesNo Please select: yes or no.

Mailing Address(*)

Please enter your mailing address.

Mailing City(*)

Please enter your city.

State(*)

Please select your state.

Zip Code(*)

Please enter your ZIP code.

Mobile Phone Number

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Home Phone Number

Invalid Input

Email Address

Invalid Input

Social Security Number

Invalid Input

Do you receive disability benefits?

YesNo Invalid Input

Date of Birth

Invalid Input

Age

Invalid Input

Are you employed?

YesNo Invalid Input

Gender

Male

Female

Other

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Ethnicity (used for statistical purposes only)

Hispanic, Latino, or Spanish Origins

Not Hispanic, Latino, or Spanish Origins

Invalid Input

Do you have other people living in your household?

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OTHER HOUSEHOLD MEMBERS - DO NOT INCLUDE YOURSELF

Please list the other persons living in your household but not yourself. Please provide all of the information for each individual.

Household Member 1

First and Last Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 2

Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 3

Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 4

Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 5

Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

Invalid Input

Household Member 6

Name

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Relationship

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Age

Invalid Input

Social Security Number

Invalid Input

Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 7

Name

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Relationship

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Age

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Social Security Number

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Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

Invalid Input

Household Member 8

Name

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Relationship

Invalid Input

Age

Invalid Input

Social Security Number

Invalid Input

Race/Ethnicity

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Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

Invalid Input

Household Member 9

Name

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Relationship

Invalid Input

Age

Invalid Input

Social Security Number

Invalid Input

Race/Ethnicity

Invalid Input

Is this person employed?

YesNo Invalid Input

What is this person's gender?

MaleFemaleOther Invalid Input

Does this person have a Disability?

YesNo Invalid Input

Date of Birth

Invalid Input

Does anyone in your house have work income?

YesNo Invalid Input

HOUSEHOLD INCOME

WORK INCOME - List anyone in your household (18 and older) who has work income (includes self‐employment, babysittng, and other odd jobs). List additional information on a separate sheet, if necessary. ATTACH PROOF OF INCOME.

Employeed Household Member 1

Name

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Pay Period

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Gross Monthly Amount

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Employer Name

Invalid Input

Employeed Household Member 2

Name

Invalid Input

Pay Period

Invalid Input

Gross Monthly Amount

Invalid Input

Employer Name

Invalid Input

Employeed Household Member 3

Name

Invalid Input

Pay Period

Invalid Input

Gross Monthly Amount

Invalid Input

Employer Name

Invalid Input

B. LAST EMPLOYMENT - If you or any adult (18 or older) member of your household is unemployed at the time of this application, list the most recent employment below.

Unemployed Household Member 1

Name

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Where Last Employed

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When Employment Ended

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Unemployed Household Member 2

Name

Invalid Input

Where Last Employed

Invalid Input

When Employment Ended

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Unemployed Household Member 3

Name

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Where Last Employed

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When Employment Ended

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Attach copies of last month's pay stubs

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Household Member 1

Who receives it?

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How often Paid?

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Gross Monthly Amount

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Income Provider

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Household Member 2

Who receives it?

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How often Paid?

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Gross Monthly Amount

Invalid Input

Income Provider

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Household Member 3

Who receives it?

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How often Paid?

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Gross Monthly Amount

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Income Provider

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Attach proof of non-work income

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D. RESOURCES - Does anyone in your home have any of the following?

Does anyone in your household have cash on hand?

YesNo Invalid Input

Name

Invalid Input

Amount

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Where?

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Does anyone in your household have a checking account?

YesNo Invalid Input

Name

Invalid Input

Amount

Invalid Input

Where?

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Does anyone in your household have any other bank accounts / CD's?

YesNo Invalid Input

Name

Invalid Input

Amount

Invalid Input

Where?

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Does anyone in your household have any Stocks or Bonds?

YesNo Invalid Input

Stock / Bond details

Name(s) of Person

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Amount

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Where?

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Does anyone in your household have any other resources?

YesNo Invalid Input

Other Resources (list)

Name(s) of Person

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Amount

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Where?

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Is your household in need of crisis assistance?

YesNo Invalid Input

CRISIS APPLICANTS ONLY:

If your household is in need of crisis assistance, please indicate below:

I have a past due balance on a utility bill. Invalid Input

HeatingElectricity Invalid Input

My home energy utility has been disconnected. Invalid Input

Date Disconnected

Invalid Input

HeatingElectricity Invalid Input

I have received notice that my home energy utility will be disconnected. Invalid Input

Date of Disconnection

Invalid Input

HeatingElectricity Invalid Input

My heating fuel is at or below 20% of the tank capacity and the fuel supplier will not deliver additional fuel without payment. Invalid Input

I have 3 weeks^* supply or less heating fuel (wood, coal, or other heating fuel not kept in a tank) and the fuel supplier will not deliver additional fuel without payment. Invalid Input

I have received an eviction notice which is partly due to my failure to pay my heating and/or electricity expenses to my landlord. Invalid Input

HeatingElectricity Invalid Input

I need assistance to pay a deposit to have my utility connected/reconnected. Invalid Input

HeatingElectricity Invalid Input

Is your crisis life threatening?

YesNo Invalid Input

Please explain:

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UTILITY/RENT INFORMATION

Do you rent or own your home?

RentOwn Invalid Input

Landlord's Name

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Landlord's Phone

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Landlord's Email

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Which utilities are included in your rent? (Check all that apply)

ElectricityNatural Gas Invalid Input

Attach a copy of your lease that says utilities are included in your rent

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HOME ENERGY SUPPLIER INFORMATION

My residence is ALL ELECTRIC

YesNo Invalid Input

Name of Primary Heating Supplier

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Account Number

Invalid Input

Other:

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Is your heating bill in your name?

YesNo Invalid Input

Whose name is the account in?

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Does this person live with you?

YesNo Invalid Input

What is this person's relationship to you?

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Is this account closed?

YesNo Invalid Input

Do you need assistance with a secondary heating supplier?

YesNo Invalid Input

SECONDARY HEATING SUPPLIER IS OPTIONAL, COMPLETE ONLY IF YOU WANT ASSISTANCE WITH THIS BILL.

Name of Secondary Heating Supplier

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Account Number

Invalid Input

Other:

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Is your heating bill in your name?

YesNo Invalid Input

Whose name is the account in?

Invalid Input

Does this person live with you?

YesNo Invalid Input

What is this person's relationship to you?

Invalid Input

Is this account closed?

YesNo Invalid Input

Name of Electric Supplier:

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Account Number:

Invalid Input

Is this account closed?

YesNo Invalid Input

Is your Electric bill in your name?

YesNo Invalid Input

Whose name is the account in?

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Does this person live with you?

YesNo Invalid Input

What is this person's relationship to you?

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Attach copies of each bill

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VERIFICATION OF IDENTITY (ID)

You must attach proof of identity. Acceptable proof includes A READABLE COPY of any VALID document that reasonably establishes identity such as:

Arkansas Driver's License

Voter registration card

A recent paycheck stub

Federal, state, or local government issued ID

ID card for health benefits or other assistance

U.S. Military Card or dependant's card

Work or school ID card with photograph

Upload your proof of identity:

Invalid Input

WEATHERIZATION SERVICES (WAP)

Would you like to be referred for weatherization services?

YesNo Invalid Input

I want to be referred for emergency HVAC repair or replacement only.

YesNo Invalid Input

I am interested in attending workshops to learn more about how to reduce my home energy needs and other life skills, such as prioritizing household expenses.

YesNo Invalid Input

APPLICANT'S RIGHTS AND RESPONSIBILITIES

I understand that my application will be shared with the providers of the above selected additional services.
I understand the information on this application will be kept confidential and only be shared as indicated. No information will be sold, loaned, rented or otherwise disclosed except as indicated on this application.
I understand that I have the right to appeal any decision regarding this application which I consider improper, any delay in decision or delivery of services, and any disagreement with benefit amount.
I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.
I authorize the LIHEAP affiliate to share informaƟon relaƟng to my applicaƟon with my uƟlity service provider(s) to determine my eligibility or benefit amount.
I give permission to the Arkansas Energy Office (AEO) to use information provided on my application for purposes of reporting, research, evaluation, and analysis of the program.
I authorize my utility supplier (s) to release my account information to Arkansas Energy Office (AEO) or its designee ( s ).
I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be responsible for monitoring or taking any steps to ensure that the LIHEAP office main‐ tains the confidentiality of the data or uses the data as I have authorized.
I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political belief.
I understand that my signature on this application authorizes the agency to verify information about me or any household member and/or use it as a release to secure information needed to determine my eligibility for services.
I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding me and/or household members, I must repay the cost of any assistance and may face penalty of criminal prosecution.
The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury.

Applicant's Signature

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ARKANSAS LIHEAPApplication for Utility Bill Assistance

APPLICANT - PLEASE PUT YOUR NAME AND INFORMATION HERE

OTHER HOUSEHOLD MEMBERS - DO NOT INCLUDE YOURSELF

HOUSEHOLD INCOME

CRISIS APPLICANTS ONLY:

UTILITY/RENT INFORMATION

HOME ENERGY SUPPLIER INFORMATION

VERIFICATION OF IDENTITY (ID)

WEATHERIZATION SERVICES (WAP)

APPLICANT'S RIGHTS AND RESPONSIBILITIES

ARKANSAS LIHEAP
Application for Utility Bill Assistance