FY15 LIHEAP Application 1262 3155
User Manual: 1262-3155
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HOW TO APPLY STEP 1 Complete the LIHEAP Application (Basic Intake Form), filling in all blanks. Shaded box is for office use only. Names, social security numbers, birth dates, and income must be reported for EVERY PERSON currently living in the home. Documentation for social security or USCIS numbers will be required. If you have questions about LIHEAP or need help with the application you may dial: 2-1-1 or toll free 1-866-469-2211, Monday – Friday, 8 am – 4:30 pm Application by mail should be sent to: HACAP PO BOX 490 HIAWATHA IA 52233 Please include all required documents. Please use the codes provided below when filling out the household member information on the application Sex: F = Female M = Male Race: 1 = Black or African American 2 = White 3 = American Indian or Alaska Native 4 = Asian 5 = Native Hawaiian or Pacific Islander 6 = Multi-Race (any 2 or more of the above) 7 = Other Ethnicity: H = Hispanic origin N = Non-Hispanic origin Education (highest level of education completed): 1 = 0-8th grade 2 = 9-12th grade (still in school) 3 = High School grad/GED 4 = 12th + some post secondary 5 = 2 or 4 year college grad 6 = Non-HS grad/No GED Relationship to Applicant: 0 = Applicant 1 = Spouse 2 = Child 3 = Foster Child 4 = Grandchild 5 = Parent 6 = Grandparent 7 = Other Relation 8 = Not Related 9 = Sibling Marital Status: 1 = Single 2 = Married 3 = Separated 4 = Divorced 5 = Widowed Disability: 1 = Mental 2 = Hearing 3 = Deaf 4 = Speech 5 = Visual 6 = Emotional 7 = Orthopedic 8 = Other 9 = None Medical Insurance: 1 = Medicare 2 = Medicaid (Title 19) 3 = Private 4 = None 5 = Unknown 6 = Hawk-I 7 = Iowa Health & Wellness Veteran: Y or N STEP 2 Gather the necessary documents to verify social security or immigration numbers, utilities and income. Social Security or Immigration Number Verification for every Member of the Household: Original documents must be presented and will be copied by HACAP staff. Please provide ONE of the following for each person in the household: q Social Security Card q Financial statement showing the Social Security number q Payroll stub showing the Social Security number q Military ID card showing the Social Security number q Printout from the Social Security Admin received for a new card application, or to replace a lost or stolen card. This print out must show your social security number on it. q I-94 card showing an USCIS number Utility Bills: Include a copy of your most current heating and electric bill(s) or any other documents showing your energy supplier and account number. Please provide ALL of the following: q Heating bill q Electric bill q Rental agreement (if heat is included in your rent) q Landlord’s name, address, and phone number Revised 9/14 Income Verification: Use this checklist to determine what type of documentation you will need to provide with your application for your household. All sources of income must be verified for the same time frame, whether using the 3-month or 12month option. Wages/Salary (gross income) q Federal tax return or W-2 forms from previous year. q Paid monthly: 3 pay stubs back from the date of application q Paid twice a month: 6 pay stubs back from the date of application q Paid every two weeks: 7 pay stubs back from the date of application q Paid weekly: 13 pay stubs back from the date of application q Paid daily: pay stubs for every day worked 13 weeks back from the date of application q If you do not have your tax return or pay stubs, you may provide a printout from your employer, on company letterhead showing your gross wages (before taxes and deductions) received during the 90 days back from the date of application. Self-Employment/Farm Income/Rental Income q Federal tax return from previous year Social Security or SSI Benefits (one of the following) q Copy of your monthly check q Award letter stating your monthly amount q 1099 or statement from SSA showing your annual amount q Bank statement (if direct deposit) showing the monthly amount Pension or Veteran Benefits (one of the following) q Copy of your monthly check q Award letter stating your monthly amount q Bank statement (if direct deposit) showing the monthly amount Child Support/Alimony (one of the following) q Printout from Child Support Recovery or Friend of the Court. You can get a printout from the Child Support Recovery website: https://childsupport.dhs.state.ia.us. q Court order or divorce decree stating monthly payment amounts q Statement from payee and copy of most recent check FIP (one of the following) q Award letter from DHS q Copy of your monthly check q Bank statement (if direct deposit) showing the monthly amount Workers Compensation q Letter stating the benefit amount, how often paid, start/end date of benefits Unemployment Benefits (one of the following) q Printout from Workforce Development/Unemployment Services q Letter stating the benefit amount, how often paid, start/end date of benefits No Income: If the entire household has had NO regular income in the past 13 weeks, complete the Verification of Minimal Income form attached to the application to explain how your basic needs are being met. You must have a third party complete the bottom of the Minimal Income form listing their name and a phone number where they can be reached. HACAP is required to contact the third party listed on the form to determine your eligibility. Revised 9/14 VERIFICATION OF MINIMAL INCOME For ________________________________________ (Applicant Name) Have you, or has any member of your household, had income from any of these sources during the past three months? If your answer is yes to any of the following questions, please list the approximate date and amount received. Employment Social Security SSI Veterans Benefits Military Allotment Pension FIP Child Support Alimony Unemployment Strike Benefits No _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Yes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Dates/Amounts ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ ______________ No Workers Compensation_____ Insurance Benefits _____ Rental Property _____ Interest/Savings, CDs _____ Loans _____ Savings _____ Scholarships, Grants _____ Food Stamps _____ Relief/Gen Assistance _____ Friends or Family _____ Other _____ Yes _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Dates/Amounts __________________ __________________ __________________ __________________ __________________ __________________ __________________ amounts not needed __________________ __________________ __________________ Please describe how your household has paid for the following basic needs during the past three (3) months: Rent or Mortgage Payment: __________________________________________________________________________ Food: ____________________________________________________________________________________________ Utility/Heating Bills: ________________________________________________________________________________ I certify that the information provided on this form is true and correct to the best of my knowledge. I declare that I am the only person in my household who has or will apply for this program. Any willful misrepresentation of the information on this form is subject to penalty of law. I authorize the agency processing this form to verify the information given above. Applicant: _____________________________________________ Date:___________________ Applicant’s Address: ____________________________________________________________________ Must be completed by a third party NOT in the household Prior to approving this application the agency will contact this 3rd party to verify authenticity Verified By: (Intake Workers Initials) Applicant is known to me and the above information is correct. ____________________________________________________ 3rd Party Signature _________________________ Date __________________________________________________ Printed Name __________________________ Phone Number Revised 9/14 Office Use Only Disconnect ___________Posted _____ Furnace Yes No Hawkeye Area Community Action Program, Inc. LIHEAP Basic Intake Form Date Stamp Last Name_______________________ First Name__________________MI____ E-mail Address______________________________ Street Address_______________________________________________ City______________________ State______ Zip__________ Mailing Address (if different) _____________________________________ City______________________ State______ Zip_________ Primary Phone ____________________(Circle One Home/ Cell) Alternate Phone _________________________(Circle One Work/Message/Cell) HOUSING STATUS: qOwn qRent qHomeless qBuying qOther FAMILY TYPE: qFemale single parent qMale single parent If Homeless/Other indicate situation:____________________ qAdults w/child(ren) Total # of Household Members: _________ qSingle qAdults-no children Native language if other than English:_____________________ HOUSEHOLD MEMBERS (including yourself) Refer to attached sheet for codes to use in this section Name (first and last) Date of Birth Soc Sec or USCIS Number ü Sex Race Ethnicity Education Relation To Applicant Marital Status Disaability Vet Medical Ins If more than 5 household members please attach a separate sheet. INCOME SOURCES First Name LIHEAP/WEATHERIZATION INFORMATION Sources (Please list all sources for all household members) How Often Paid PRIMARY HEAT SOURCE Check One Only qFuel Oil qElectric qGas qPropane qWood qCoal qCorn qOther______ HOUSING TYPE qHouse qMobile Home q2,3,or 4 Units/Apts in Bldg q5+ Units/Apts in Bldg qOther______________________________________ LANDLORD (must be completed for all renters) Name_____________________________ Phone_________________ How many in your household work ________ Address__________________________________________________ How much is your Rent/Mortgage (circle one) $__________ City______________________State__________Zip_______________ Is anyone in your household: qA Farmer Are you having problems with your furnace? Do you have heat? qYes qYes qNo qNo If you rent, are heating costs included in the rent? qYes qNo qYes qNo Do you have savings/CDs/investments over $15,000? qYes qNo q A Migrant Worker qHome bound qA Seasonal Farm Worker Do you receive: Food stamps? Medical Aid? General Assistance? VENDORS (If yes, we need copy of the lease.) qYes qYes qYes qNo qNo qNo Are you on Section 8 or Subsidized Housing? (Is your rent based on a percentage of your income?) Heating Company_______________________Account #_______________________________Name on Acct_____________________ Electric Company_______________________Account #_______________________________Name on Acct______________________ I certify under penalty of perjury the above information is true. I give permission to the agency processing this application to acquire additional information and to share information with other organizations for the purposes of providing services to assist my household. This sharing of information is to be conducted with maximum respect for the confidentiality of the information contained in this application. If I am hereby making application for Low Income Home Energy Assistance, I further certify the following: I declare that I am the only person in the household who has or will apply for this program. Any willful misrepresentation of the information on this form is subject to a penalty of law. I assure that any energy payments received under this program will be used solely for home energy costs. I understand that by signing (either in written form or electronically) this application I am authorizing the Weatherization of my house at no cost to my family, or me but this application does not guarantee any work being done on my house. I hereby give permission to the State of Iowa, the U.S. Department of Energy, U.S. Department of Health and Human Services and the agency processing this application to obtain additional information from my energy supplier about my household energy usage and payment history. I also give permission to the State of Iowa to release application information to my energy supplier, and for my heating and electric company to provide details about my account and energy use to the energy assistance and weatherization programs. I understand this statement. Applicant signature: X____________________________________________________________________________ Date: _________________________ Intake worker signature: ____________________________________________________________________________ Date: ________________________ Revised 9/14
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