SFN 62, Emergency Assistance Application/Assessment 415-65-30
(Revised 10/02 ML #2812)
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(Appendix H)
This form is available through the Department of Human Services and may also be obtained electronically via E-Forms.
The Emergency Assistance Application/Assessment" must be completed and in the case file for each emergency assistance request.
SFN 62 is designed to be used by both LIHEAP and Energy Share of North Dakota. If the customer needs assistance from both agencies, the originating agency should make a copy of the form and send it to the other agency to avoid having the customer complete two application forms.
"APPLICATION"
The "application" side of SFN 62 is designed to be completed by the applicant. The worker should check for completeness.
Identification
The name and social security number should be the same as the head of household used for the Heating Assistance Program.
County: Enter the county of residence.
Address: Enter the mailing address.
Phone: Enter a number at which the family can be reached.
Ages: Enter the ages of all the household members. The head of household should be entered first.
Emergency Assistance Needed
Allow the applicant to explain in his/her own words what is needed. Ask for clarification of amounts and months of service, if necessary.
Why Assistance Is Needed
Allow the applicant to explain what happened that caused the emergency. This perception of the causes can be a starting point for later discussion regarding an "Action Plan" (SFN 11), if appropriate.
Applicant's Efforts to Resolve Crisis
Have the applicant describe what he/she has done to handle the crisis, especially any contacts with the supplier. Request information regarding the amount he/she has paid for energy bills in the last 6 months.
Net Income
Request income information for all household members for the current month, including who received the income and its source. This should be net, "take-home" pay. Request information regarding checking and savings account balances.
Monthly Expenditure
Expenses should be only those for the current month and should not include any arrearages so you have an accurate picture of usual, on-going expenses. Payments required on arrearages can be noted as "other mandatory expenses."
If the applicant receives housing assistance or food stamps, only the amount the applicant pays "out-of-pocket" should be listed.
Plan
Allow the applicant to describe in his/her own words what can be done to prevent future crisis. This will be helpful later in developing an "Action Plan."
Signature
Have the applicant sign and date the application.
"ASSESSMENT"
The "Application Assessment" is to be completed by the worker . This section should not duplicate information given by the applicant. It should be used to clarify and evaluate the applicant's information.
Service Requested
CIRCLE either LIHEAP or Energy Share and check the type(s) of assistance requested. Describe the cost involved, any deadlines which apply, how the service requested will affect the health, life, and/or safety of the applicant household.
Other Assistance Received
Enter the amounts and type of other assistance received, when it was paid, and how much the applicant household has paid toward heating costs.
Assessments
Item 1: Include your assessment of all financial data including income, savings, credit, payment record.
Item 2: Include your assessment of the applicant's efforts to arrange payments with the supplier or secure assistance from other sources.
Item 3: Identify any factors that contribute to the emergency or the applicant's ability/inability to improve circumstances, and to your decision to approve/deny the application.
Evaluation and Plan
Summarize your recommendations for referrals or other action plan, and evaluate the household's motivation and future outlook for self-sufficiency.
SFN 11, "Action Plan" completed? Check "yes" or "no". NOTE that completion of SFN 11 is mandatory if the worker is making any referrals or recommendations for action on the part of the applicant. If your assessment is that no action is needed or feasible at this time, check "no" and do not complete SFN 11. Although we would like to see all applicants independent, it is important to recognize which people have reached the highest level of independence possible for them. Likewise, there may be justifiable reasons the applicant cannot work on problem areas such as inaccessibility of services, mental or physical illness, etc. Note the reason an Action Plan is not appropriate at the time of the Emergency application.
CAUTION: If the applicant needs to apply to both agencies, a copy of this form may be sent with the applicant so he/she does not need to complete the application twice. Therefore the worker needs to be careful in the choice of words on the assessment side of the form. Anything written on the form should have been discussed with the applicant. If you believe the customer doesn't have the ability to learn new skills, your assessment could read, "Mr. is doing all he can to support his family."
LIHEAP Action (LIHEAP Workers Only)
If the request is within the amounts the county worker can approve, no State action is needed. Check whether approved or denied and describe what is to be paid. The county worker needs to sign and date the action taken.
If the assistance requested would require State Office approval, the county worker must first decide whether the county recommends approval. If the county does not recommend approval, the State Office does not need to be contacted and the form does not need to be sent to the State. If the county recommends approval, the emergency application needs to be completed on the LIHEAP System so the State Office can view, to approve or not approve.
Energy Share Action (Energy Share Workers Only)
Complete and sign as instructed by Energy Share policy.
"SUMMARY"
Completion of this section is extremely important to ensure that LIHEAP and Energy Share do not duplicate their payments.
Bills Requested
The left column serves as a "check" to note the age of the bill. (Refer to 415-50-05-30 for bills not eligible for payment by LIHEAP.)
List the oldest bills first.
Enter the date the meter was read or the fuel delivered for each bill. DO NOT combine the bills.
Enter the amount of the bill.
Enter the type of service provided (oil, electric heat, electric lights, etc.)
Since customers frequently have an emergency for both heating fuel and electric lights, there is space to show both even if the meter read date is the same. See sample Summary #1.
If the home is heated with electricity, whichever agency first sees the applicant should enter the total electric bill and indicate "elec heat & lights" under "type."
Payments Authorized
For each bill entered, show the amount your agency will pay, the amount the applicant has paid, and any amount deferred to monthly payments.
Sample Summary #1 (Application Taken December 15)
BILLS REQUESTED
|
|
DATE |
AMOUNT |
TYPE |
|
90 Days |
Sept. 15 |
25 |
N. Gas |
|
|
Sept. 15 |
30 |
Lights |
|
60 Days |
Oct. 15 |
40 |
N. Gas |
|
|
Oct. 15 |
30 |
Lights |
|
30 Days |
Nov. 15 |
60 |
N. Gas |
|
|
Nov. 15 |
35 |
Lights |
PAYMENTS AUTHORIZED
|
DATE |
LIHEAP |
EN SH |
APPL. |
DEFER |
|
Sept. 15 |
20 |
|
5 |
|
|
Sept. 15 |
|
20 |
10 |
|
|
Oct. 15 |
40 |
|
|
|
|
Oct. 15 |
|
20 |
|
0 |
|
Nov. 15 |
50 |
|
10 |
|
|
Nov. 15 |
|
20 |
5 |
10 |
Sample Summary #2 (Electric Heat & Lights, Propane)
BILLS REQUESTED
|
|
DATE |
AMOUNT |
TYPE |
|
90 Days |
Oct. 15 |
100 |
Elec Ht & Lts |
|
|
|
|
|
|
60 Days |
Nov. 15 |
100 |
Elec Ht & Lts |
|
|
|
|
|
|
30 Days |
Dec. 15 |
150 |
Propane (Back up Fuel) |
PAYMENTS AUTHORIZED
|
DATE |
LIHEAP |
EN SH |
APPL. |
DEFER |
|
Oct. 15 |
75 |
15 |
10 |
|
|
|
|
|
|
|
|
Nov. 15 |
75 |
25 |
|
|
|
|
|
|
|
|
|
Dec. 15 |
75 |
|
25 |
50 |
