SFN 62, Emergency Assistance Application/Assessment 415-65-30

(Revised 10/1/09 ML #3195)

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SFN 62 is to be used by LIHEAP and for referral to Energy Share of North Dakota. If the customer needs assistance from Energy Share, the LIHEAP worker should make a copy of the form and send it to Energy Share.

 

There are two sections of the form: 1) Application and 2) Agency Use Only. The "APPLICATION" section is to be completed by the household. The "Agency Use Only" section is completed by the worker.

 

The worker should check for completeness. Incomplete applications are not acceptable. The worker should assist the household to complete the application. No uncompleted applications or unsigned applications will be entered into the LIHEAP system.

 

"APPLICATION"

 

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

The household will fill in the services that are needed.

 

Name Of Company That Fuel Is Purchased From

Who do they receive fuel from.

 

Name On Account, Account Number

Household should list whose name is on the account and an account number if there is one. If there is not account number, "none" should be written.

 

Dollar Amount Of Emergency Assistance You Are Applying For

LIHEAP needs to know exactly how much the household needs to take care of the emergency only.

 

How Much Have You Paid On Your Energy Bills In The Last 6 Months?

Household needs to tell LIHEAP this because it may be a determining factor whether they receive emergency assistance or not.

 

List The Reasons You Are Applying For Emergency Assistance

Allow the household 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.

 

Household's Efforts To Resolve Crisis (Next Two Lines)

Have the household describe what he/she has done to handle the crisis, especially any contacts with the supplier.

 

Plan

Household should describe in his/her own words what can be done to prevent future crisis. This will be helpful later in developing an "Action Plan" (SFN 11).

 

List Net Income Of Each Household Member For The Month Of Emergency Application

Household should list income information for all household members for the current month, including who received the income and its source and employer. This should be net, "take home' pay.

 

List Assets of Each Household Member

Request information regarding checking, savings and other account balances.

 

Expenditures For The Month Of Application

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 household receives housing assistance or food stamps, only the amount the applicant pays "out-of-pocket" should be listed.

 

See Eligibility Guidelines 415-50-10-10 to determine the allowable expenses for one month.

 

Note: Verifications are only needed if information is questionable.

 

Signature

Have a household member sign and date the application.

 

"AGENCY USE ONLY"

 

Local Action: Check whether approved or denied and describe what is to be paid.

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. 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.

 

If the application is denied the worker should:

1. Send the household a denial notice.
2. Inform the person of their right to appeal
3. Keep the application with the case file and narrate on the LIHEAP system why the application was denied.

 

Signature Of LIHEAP Representative

Worker should sign the date the action is taken.

 

Emergency Assistance Payments

Payments should be no more than 90 days from the date of the emergency assistance application.

 

Pmt Date	Reason Code	Heat Type	Usage	Invoice No.	Amt Requested	Amt Paid

 

Use the above guide (SFN 62) to help you monitor the payments that you paid for the household. If another county worker assists the household then they will know the emergency assistance history.

 

Questions to ask about the household

1. Does this bring household current? Current costs that will not maintain or restore home energy services due to shut-offs occurring as a result of unpaid arrearages are not eligible.  Ineligible Energy Costs 415-50-05-30
2. Referred for Self Reliance? If the household is having difficulty making ends meet do they need help to reduce their monthly costs or do they need employment etc.?
3. Referred for Energy Share? Do they also need assistance with their non-heat costs? The referral should be sent to the nearest Community Action Agency. Electric Utilities 415-50-05-25
4. SFN 11 Completed? 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 household. 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 households 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 household 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.
5. List Other Agencies Referred To? What other agencies can they be referred to? If you are going to refer them to Self Reliance make some suggestions to Self Reliance about problem areas.

 

"ASSESSMENT"

 

 Assessments are to be completed on the LIHEAP System under Emergency Assistance.  There is a screen on the system where you can type your assessment.

 

PR3 RETURN TO MENU  ENTER NARRATIVE (Assessment)

 

When you write an assessment consider the following factors to determine eligibility:

 

 

• Income- Determine eligibility by using the net income in the month of application.  Do not average 3 months.
• Expenses- Look at the expenses the household claims to have for the current month.
• Assets- Households should have no assets except $5000 each for each person over 60 years of age.

 

Include your assessment of all financial data including credit and payment record.

 

Include your assessment of the household's efforts to arrange payments with the supplier or secure assistance from other sources. Identify any factors that contribute to the emergency or the household's ability/inability to improve circumstances, and to your decision to approve/deny the application.

 

If appropriate add information about making household current with vendor, referral to Self Reliance, referral to Energy Share, completion of the SFN 11, and other agencies the household is being referred to.

 

Evaluation and Plan

Summarize your recommendations for referrals or other action plan, and evaluate the household's motivation and outlook for self-sufficiency