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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

Please select your county.
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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

Please enter your last name.
Please enter your first name.
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Please enter your mailing address.
Please enter your city.
Please select your state.
Please enter your ZIP code.
Please select: yes or no.

Please enter your mailing address.
Please enter your city.
Please select your state.
Please enter your ZIP code.

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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
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Household Member 2
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Household Member 3
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Household Member 4
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Household Member 5
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Household Member 6
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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
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Employeed Household Member 2
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Employeed Household Member 3
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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
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Unemployed Household Member 2
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Unemployed Household Member 3
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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
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Household Member 2
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Household Member 3
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D. RESOURCES - Does anyone in your home have any of the following?


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Other Resources (list)
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Other Resources (list)
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CRISIS APPLICANTS ONLY:

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

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UTILITY/RENT INFORMATION

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HOME ENERGY SUPPLIER INFORMATION

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

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SECONDARY HEATING SUPPLIER IS OPTIONAL, COMPLETE ONLY IF YOU WANT ASSISTANCE WITH THIS 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
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WEATHERIZATION SERVICES (WAP)

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APPLICANT'S RIGHTS AND RESPONSIBILITIES

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