Date Received:

Enter the date a completed and signed application is received in the county social service board office. This is the date which will later be entered on the "Household Data" screen in 'Date of Application.’

Case Number:

The use of a case number for LIHEAP is NOT mandatory. However, if no case number is used, the two-digit county identification number MUST still be entered on the "Add Household Data" screen in the first two positions.

Part I

Name:

Enter the name of the head of the household.

Address, County:

Enter for the home to be heated.

Part II - Expenses

Medical:

Check "yes" or "no" to any medical expenses incurred since the previous July 1. Proof of the expenses must be provided. See 25-05-05-05 for the complete list of allowable expenses.

Child Care:

Check "yes" or "no," enter the amount, and indicate how often (weekly, monthly, etc.) it is paid. Note: Child care eligible for deduction must be related to work, training or education.

Alimony/Child Support:

Check "yes" or "no" to alimony/child support paid and provide the amount.

Part III

Type of Home:

Be sure one of these is checked, as it is needed to determine the amount of benefits.

# of Bedrooms:

This is to include the number of rooms in the living unit which are designed to be sleeping areas. Indicate the number of bedrooms on each floor. If, however, the apartment does not have a separate rate sleeping room such as in some "efficiency" apartments which have only a "hide-a-bed" in the main living area, the home would count one bedroom. The number of bedrooms establishes the size of the dwelling for purposes of finding the average cost of heating from the cost-consumption tables.

Part IV

Type of Heat:

The type of heat should be that which the applicant expects to be using the balance of the heating season. (NOTE: This is the ONLY question in this section which must be completed if the applicant is a renter whose rent payment includes the cost of heat.)

If more than one type of fuel is used, label which type is the "primary" source of heat. If a primary source cannot be identified, benefits will be established using the type of heat which is the more costly. Both primary and secondary heat sources will be identified on the computer "Household Data" screen

Shut-Off Notice/Need Fuel:

These two questions are to assist the county social service office in determining when an application must be processed under the emergency procedures outlined in 15-05-20.

Supplier Name, Address:

This should be the supplier of the primary source of heat that the applicant intends to use for the balance of the heating season.

Name on Bill:

Enter the name of the household member whose name is on the heating supplier’s account.

Account #:

This should be obtained if at all possible whenever the supplier uses customer account numbers. It is mandatory for NSP, MDU, Ottertail, and Vision Energy.

The applicant must provide copies of ALL heating bills, paid or unpaid, incurred since October 1 of the current fiscal year, for which a Miscellaneous Payment will be made. (See 35-20-10).

Part V

Weatherization and Other

Services:

Your signature on this application will permit the Community Action Agency in your area to contact you with information about weatherization services that can save you money on energy costs. There is no cost to you, and you are under no obligation.

Community Action Agencies also offers other services that may be of help to you. The Self-Reliance Program can help you with budget counseling and other needs. Energy Share can help with non-heat utility bills in emergency situations. Ask your county worker for more information.

Part VI

Do you want your furnace

Cleaned?  ¨ Yes   ¨ No

Vendor ______________

Do you want your chimney

Cleaned?  ¨ Yes ¨ No

Vendor _______________

Reimbursements:

Asks applicant if he/she has paid for any fuel delivered since October 1. The county should review the applicant’s responses to determine if reimbursements may be appropriate.

Certification and Authorization to Release Information:

The county social service office should draw the attention of the applicant to the certification statement whenever there is a face-to-face or telephone contact. When the application is received in the mail, and there is any indication that the applicant may not understand the full implication of his responsibilities as stated in the certification statement, the county worker should contact the applicant and discuss the applicant responsibilities with him.

Signature:

The application must be signed by a member of the household before the application can be approved.

Right to Appeal:

The county social service office representative should briefly give the applicant a verbal explanation of his rights to appeal and should draw his attention to the written statement of his rights to appeal which will be mailed with his ANotice of Action."