LIHEAP Application

ARKANSAS ENERGY OFFICE
ARKANSAS HOME ENERGY ASSISTANCE PROGRAM APPLICATION

Affordable Care Act (ACA) - The comprehensive health care reform law was enacted in March 2010. The law has 3 primary goals: (1) Make affordable health insurance available to more people. The law provides consumers with subsidies ("premium tax credits") that lower costs for households with incomes between 100% and 400% of the federal poverty levels; (2) Expand the Medicaid program to cover all adults 19 - 64 years of age with income below I 00% of the federal poverty level; and (3) Support innovative medical care delivery methods designed to lower the costs of health care generally.

FOR MORE INFORMATION GO TO HEALTHCARE.GOV OR CALL 1-800-318-2596

County of Residence(*)

Please select your county.

What bill(s) do you need assistance with? (check up to two)

GasElectricityPropaneFuel OilOther Invalid Input

What bill do you need assistance with?

Invalid Input

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

Invalid Input

Mailing 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 street address?

YesNo Please select: yes or no.

Street Address

Please enter your mailing address.

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 have a Disability?

YesNo Invalid Input

Date of Birth

Invalid Input

Age

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Gender

MaleFemaleOther Invalid Input

Race

WhiteBlackSpanish American/HispanicOriental; Asian, or Pacific IslanderNative American or Alaskan NativeOtherUnknown Invalid Input

How many people live in your household, not including yourself?

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OTHER HOUSEHOLD MEMBERS - DO NOT INCLUDE YOURSELF

Please list the other persons living in your household but not yourself. Please complete all items.

Household Member 1

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 2

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 3

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 4

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 5

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Household Member 6

Name

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Race

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Relationship

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Social Security Number

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Age

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Does this person have a Disability?

YesNo Invalid Input

Date of Birth

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Does anyone in your house have work income?

YesNo Invalid Input

HOUSEHOLD INCOME

A. WORK INCOME - List anyone in your household who has work income (Includes self-employment, babysitting, et cetera)
YOU MUST ATTACH COPIES OF LAST MONTH'S PAY STUBS

Employeed Household Member 1

Name

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How Often Paid

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Gross Monthly Amount

Invalid Input

Employer Name

Invalid Input

Employeed Household Member 2

Name

Invalid Input

How Often Paid

Invalid Input

Gross Monthly Amount

Invalid Input

Employer Name

Invalid Input

Employeed Household Member 3

Name

Invalid Input

How Often Paid

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Gross Monthly Amount

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Employer Name

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

YOU MUST ATTACH PROOF OF THIS INCOME: Child Support, Social Security Income; (SSA) Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); TEA; Alimony; Unemployment benefits; Worker's Compensation; Veterans Benefits; Retirement Benefits; Housing t:Jtility Assistance Payment; any other non-work income:

Unemployed Household Member 1

Name

Invalid Input

Where Last Employed

Invalid Input

When Employment Ended

Invalid Input

Unemployed Household Member 2

Name

Invalid Input

Where Last Employed

Invalid Input

When Employment Ended

Invalid Input

Unemployed Household Member 3

Name

Invalid Input

Where Last Employed

Invalid Input

When Employment Ended

Invalid Input

Attach copies of last month's pay stubs

Invalid Input

C. NON-WORK INCOME - List anyone in your household who receives any of the following and attach proof of this income: Child Support, Social Security Income; (SSA) Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); TEA; Alimony; Unemployment benefits; Worker's Compensation; Veterans Benefits; Housing Utility Assistance Payment; any other non-work income;

Household Member 1

Who receives it?

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How often paid?

Invalid Input

Gross Monthly Amount

Invalid Input

Non-work income from (SSA, Retirement, etc.)

Invalid Input

Household Member 2

Who receives it?

Invalid Input

How often paid?

Invalid Input

Gross Monthly Amount

Invalid Input

Non-work income from (SSA, Retirement, etc.)

Invalid Input

Household Member 3

Who receives it?

Invalid Input

How often paid?

Invalid Input

Gross Monthly Amount

Invalid Input

Non-work income from (SSA, Retirement, etc.)

Invalid Input

Attach proof of non-work income

Invalid Input

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

Invalid Input

Where?

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Does anyone in your household have a checking account?

YesNo Invalid Input

Name

Invalid Input

Amount

Invalid Input

Where?

Invalid Input

Does anyone in your household have any other bank accounts?

YesNo Invalid Input

Name

Invalid Input

Amount

Invalid Input

Where?

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Does anyone in your household have any other resources?

YesNo Invalid Input

Other Resources (list)

Name(s) of Person

Invalid Input

Amount

Invalid Input

Where?

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Does anyone in your household have any more other resources?

YesNo Invalid Input

Other Resources (list)

Name(s) of Person

Invalid Input

Amount

Invalid Input

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

HeatingElectricity Invalid Input

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

HeatingElectricity Invalid Input

My heating fuel is at or below 10% 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

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:

Invalid Input

UTILITY/RENT INFORMATION

Do you rent or own your home?

RentOwn Invalid Input

Landlord's Name

Invalid Input

Landlord's Phone

Invalid Input

Is your energy cost included in your rent payment?

YesNo Invalid Input

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

Invalid Input

HOME ENERGY SUPPLIER INFORMATION

You must complete information on BOTH - PRIMARY Heating Source AND ELECTRIC - AND include copies of EACH bill.

My residence is ALL ELECTRIC

YesNo Invalid Input

Name of Primary Heating Supplier

Invalid Input

Account Number

Invalid Input

Natural GasElectricityFuel Oil or KerosenePropane, Butane, LP, or PPGOther Invalid Input

Other:

Invalid Input

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

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

Invalid Input

Account Number

Invalid Input

Natural GasElectricityFuel Oil or KerosenePropane, Butane, LP, or PPGOther Invalid Input

Other:

Invalid Input

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:

Invalid Input

Account Number:

Invalid Input

Is this account closed?

YesNo Invalid Input

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

Attach copies of each bill

Invalid Input

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 home Weatherization?

YesNo Invalid Input

May LIHEAP send your application to WAP?

YesNo Invalid Input

APPLICANT'S RIGHTS AND RESPONSIBILITIES

I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in decision or delivery of services.

I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.

I authorize the contracted agency to release information relating to my application for LIHEAP to my Energy Supplier(s) to determine eligibility. I give permission to the Arkansas Energy Office (AEO) to use information provided on this form for purposes of research, evaluation and analysis of the program.

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 maintains 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 submitting this form authorizes the agency to make any investigation concerning me or any household member and/or use a copy as a release of information for securing 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 my circumstances, 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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Signature of person helping to complete this form

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(*)

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About Us

NADC is a private non-profit organization, organized to plan and administer projects to aid in the social and economic development of northcentral Arkansas covering the counties of Fulton, Independence, Izard, Sharp and Stone.

Contact Us

Northcentral Arkansas Development Council, Inc.
1900 Lyon Street
Batesville, AR 72501
Phone: (870) 793-5765

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Our Community action agency does not discriminate on the basis of race, color, national origin, age, gender, religion, or disability status. Customer diversity is whole heartedly embraced in both our service delivery systems and hiring practices as we strive to eliminate the cause of poverty in Northcentral Arkansas.