FY15 LIHEAP Application 1262 3155
User Manual: 1262-3155
Open the PDF directly: View PDF 
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Page Count: 4
Revised 9/14
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 Marital Status: 1 = Single
M = Male 2 = Married
3 = Separated
Race: 1 = Black or African American 4 = Divorced
2 = White 5 = Widowed
3 = American Indian or Alaska Native
4 = Asian Disability: 1 = Mental
5 = Native Hawaiian or Pacific Islander 2 = Hearing
6 = Multi-Race (any 2 or more of the above) 3 = Deaf
7 = Other 4 = Speech
5 = Visual
Ethnicity: H = Hispanic origin 6 = Emotional
N = Non-Hispanic origin 7 = Orthopedic
8 = Other
Education (highest level of education completed): 9 = None
1 = 0-8th grade
2 = 9-12th grade (still in school) Medical Insurance:
3 = High School grad/GED 1 = Medicare
4 = 12th + some post secondary 2 = Medicaid (Title 19)
5 = 2 or 4 year college grad 3 = Private
6 = Non-HS grad/No GED 4 = None
5 = Unknown
Relationship to Applicant: 6 = Hawk-I
0 = Applicant 5 = Parent 7 = Iowa Health & Wellness
1 = Spouse 6 = Grandparent
2 = Child 7 = Other Relation Veteran: Y or N
3 = Foster Child 8 = Not Related
4 = Grandchild 9 = Sibling
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:
! Social Security Card
! Financial statement showing the Social Security number
! Payroll stub showing the Social Security number
! Military ID card showing the Social Security number
! 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.
! 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:
! Heating bill
! Electric bill
! Rental agreement (if heat is included in your rent)
! 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 12-
month option.
Wages/Salary (gross income)
! Federal tax return or W-2 forms from previous year.
! Paid monthly: 3 pay stubs back from the date of application
! Paid twice a month: 6 pay stubs back from the date of application
! Paid every two weeks: 7 pay stubs back from the date of application
! Paid weekly: 13 pay stubs back from the date of application
! Paid daily: pay stubs for every day worked 13 weeks back from the date of application
! 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
! Federal tax return from previous year
Social Security or SSI Benefits (one of the following)
! Copy of your monthly check
! Award letter stating your monthly amount
! 1099 or statement from SSA showing your annual amount
! Bank statement (if direct deposit) showing the monthly amount
Pension or Veteran Benefits (one of the following)
! Copy of your monthly check
! Award letter stating your monthly amount
! Bank statement (if direct deposit) showing the monthly amount
Child Support/Alimony (one of the following)
! 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.
! Court order or divorce decree stating monthly payment amounts
! Statement from payee and copy of most recent check
FIP (one of the following)
! Award letter from DHS
! Copy of your monthly check
! Bank statement (if direct deposit) showing the monthly amount
Workers Compensation
! Letter stating the benefit amount, how often paid, start/end date of benefits
Unemployment Benefits (one of the following)
! Printout from Workforce Development/Unemployment Services
! 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.
No Yes Dates/Amounts No Yes Dates/Amounts
Employment _____ _____ ______________ Workers Compensation_____ _____ __________________
Social Security _____ _____ ______________ Insurance Benefits _____ _____ __________________
SSI _____ _____ ______________ Rental Property _____ _____ __________________
Veterans Benefits _____ _____ ______________ Interest/Savings, CDs _____ _____ __________________
Military Allotment _____ _____ ______________ Loans _____ _____ __________________
Pension _____ _____ ______________ Savings _____ _____ __________________
FIP _____ _____ ______________ Scholarships, Grants _____ _____ __________________
Child Support _____ _____ ______________ Food Stamps _____ _____ amounts not needed
Alimony _____ _____ ______________ Relief/Gen Assistance _____ _____ __________________
Unemployment _____ _____ ______________ Friends or Family _____ _____ __________________
Strike Benefits _____ _____ ______________ Other _____ _____ __________________
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 Verified By:
Prior to approving this application the agency will contact this 3rd party to verify authenticity (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
Date Stamp
Hawkeye Area Community Action Program, Inc.
LIHEAP Basic Intake Form
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: !Own !Rent !Homeless !Buying !Other If Homeless/Other indicate situation:____________________
FAMILY TYPE: !Female single parent !Male single parent !Adults w/child(ren) !Single !Adults-no children
Total # of Household Members: _________ 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
"
Sex
Race
Ethnicity
Edu-
cation
Relation
To
Applicant
Marital
Status
Disa-
ability
Vet
Medical
Ins
If more than 5 household members please attach a separate sheet.
INCOME SOURCES
How many in your household work ________
How much is your Rent/Mortgage (circle one) $__________
Is anyone in your household: !A Farmer !Home bound
! A Migrant Worker !A Seasonal Farm Worker
Do you receive: Food stamps? !Yes !No
Medical Aid? !Yes !No
General Assistance? !Yes !No
VENDORS
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: ________________________
First Name
Sources
(Please list all sources for all
household members)
How
Often Paid
LIHEAP/WEATHERIZATION INFORMATION
PRIMARY HEAT SOURCE Check One Only
!Fuel Oil !Electric !Gas !Propane !Wood !Coal !Corn !Other______
HOUSING TYPE
!House !Mobile Home !2,3,or 4 Units/Apts in Bldg !5+ Units/Apts in Bldg
!Other______________________________________
LANDLORD (must be completed for all renters)
Name_____________________________ Phone_________________
Address__________________________________________________
City______________________State__________Zip_______________
Are you having problems with your furnace? !Yes !No
Do you have heat? !Yes !No
If you rent, are heating costs included in the rent? !Yes !No
(If yes, we need copy of the lease.)
Are you on Section 8 or Subsidized Housing? !Yes !No
(Is your rent based on a percentage of your income?)
Do you have savings/CDs/investments over $15,000? !Yes !No
