application: low income home energy assistance program (liheap

APPLICATION: LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)

DEPARTMENT OF HEALTH AND HUMAN SERVICES

SFN 529 (9-2023)

FOR OFFICE USE ONLY

Date Received

Case Number

WHAT IS LIHEAP?

The Low Income Home Energy Assistance Program (LIHEAP) helps pay part of the heating bills (meter read

dates/deliveries) from October through May for the home you live in if …….

• You are a home owner or renter and you pay your own heat bills.

• Your rent payment includes your cost of heat and you are not receiving housing assistance.

Applications are accepted from October 1 through May 31 (end of business day) or until program funds are used

up, whichever comes first. If May 31 falls on a weekend or holiday, the deadline for signed applications will be

the end of the first work day following May 31. Applications received June 1-September 30 are limited to

Cooling (if available) or Emergency Home Energy Services only as the regular heating season has ended.

LIHEAP APPLICATION

Please read the application carefully. Answer each question completely with printed or typed answers. Attach

another sheet if you need more space to answer questions.

If you are mailing in your application, send it to the Customer Support Center. If you are applying in

person, return the completed application to your local human service zone office. Failure to answer each

question and provide required verifications may delay processing of your application or result in a denied

application. Applications that are not signed will be returned. You can contact your Customer Support Center if

you have questions about completing this application, need help getting verifications or if you need a translator.

A worker may ask to schedule an interview to better assist in the application process. Tell the worker if it causes

a hardship for you to get to the office so other arrangements can be made.

All verifications should be submitted within 30 days from the date a completed application (completed, signed

and dated) is received by your regional eligibility team. You will be sent a “Notice of Action” letter within 45 days

letting you know whether you qualify.

HEAD OF HOUSEHOLD

Fill in the information about the person living in your home who is the “head of household”. Usually this should be the same

person whose name is on the heating bill.

Name

Email Address

Home Telephone Number Cell Phone Number

Physical Address

City

State

ZIP Code County

Have you lived at this physical address since September 1?

Yes No - Date you moved in:

Mailing Address (if different than physical address)

City

State

ZIP Code County

Clear Fields

SFN 529 (9-2023)

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HOUSEHOLD INFORMATION

Federally Recognized Tribe

Are you or any household member enrolled in a federally recognized Tribe?

Yes No

If YES, list the name of the enrolled member(s),Tribe/State Affiliation, and their tribal enrollment numbers(s)

Name Affiliation Enrollment Number

Disability

Do you or any member of your household have a disability? Yes No

If YES, who has the disability?

Indicate the following programs you currently applied to receive by using “X”

Health Care /Medicaid Supplemental Nutrition Assistance Program (SNAP)

Temporary Assistance for Needy Families (TANF)Housing Assistance

General Assistance Child Care Assistance Program (CCAP)

Other Programs

Head of Household or Spouse

Does the head of household or spouse reside away from home for education or work purposes?

Yes No

If YES:

Specify:

Head of Household

Spouse

Name

Reason

Education Work

Household Members

Relationship

to You

Social

Security Number

Date of

Birth

Age Gender

Last Grade

Completed

School

Status

Citizen

(yes

or no)

Race Ethnicity

SELF

Codes are listed below

Examples of relationships to you: spouse, mother, father, son, daughter, grandma, grandpa, aunt, uncle, cousin, brother, sister, step-

mother, step-father, step-son, step- daughter, foster child, foster parent, niece, nephew, not related.

Gender Codes: M - Male; F - Female

School Status codes: Full - Full time, Part - Part time, LP - Less than part time, NIS - Not in School

Race Codes: AL- American Indian/Alaska Native; AP- Asian; BL - Black/African American; HP - Native Hawaiian/ Pacific Islander;

WH - White; O - Other

Ethnicity codes: NH - Non-Hispanic/Latino; C - Cuban; M- Mexican/Mexican American/Chicano; P - Puerto Rican; O - Other

*PRIVACY STATEMENT: Disclosure of the social security number is voluntary and is requested for the purpose of accurate identification. Failure to

disclose a social security number will not affect participation in this program.

SFN 529 (9-2023)

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INCOME

Proof is required for all income. You will need:

• Wage earners: Provide wage stubs showing gross earnings for last month and the current month.

W2 forms are not acceptable

• Self-employed person: current, complete income tax return

• Social Security, SSI, Veteran's benefits, worker's compensation, interest, dividends, pensions, rental

income, etc.: a recent award letter or copy of the monthly check, or record of automatic bank deposit

• Unemployment compensation: statement of eligibility from Job Service

• Child support/alimony: printout of payments received

• Regular contributions from friends/relatives: signed statement from the individual

List below the GROSS income of ALL PERSONS living in your home. Please attach proof of gross income for last month

and current month. List anticipated income for next month.

ELIGIBILITY CANNOT BE DETERMINED WITHOUT THIS INFORMATION.

Wages/Tips: How often are you paid: Weekly (W), Bi-weekly (BW), Semi-Monthly (SM), Monthly (M), Other (O)

Household Members Employer

How

Often Paid

LAST MONTH

Income

THIS MONTH

Income

NEXT MONTH

Income

$ $ $

Comments about your income:

SFN 529 (9-2023)

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CHECK YES OR NO ON ALL QUESTION

Income: How often are you paid: Weekly (W), Bi-weekly (BW), Semi-Monthly (SM), Monthly (M), Other (O)

Source of Income Yes No Household Members(s)

How Often

Paid

LAST MONTH

Amount

THIS MONTH

Amount

NEXT MONTH

Amount

Social Security $ $ $

SSI $ $ $

Pensions (including

Veteran Benefits)

$ $ $

Annuities $ $ $

Rental Income $ $ $

Interest Income $ $ $

Spousal/Child

Support

$ $ $

Workers

Compensation

$ $ $

TANF $ $ $

Unemployment

Benefit

$ $ $

Other Income received or anticipated from last June 1st to next May 31st. Please provide verification

Source of Income Yes No Household Member(s) Amount Date Received Date Anticipated

Self-Employment (tax form) $

Mineral Lease/Royalties $

Lump Sum Payments $

Individual Indian Monies $

Tribal Payments $

Trusts $

Contract Payment $

Yearly Payments $

Inheritance $

Other Income $

If YES to Other Income, Specify

Does anyone outside your household deposit money into a household member's bank account?

Yes No If yes, explain:

SFN 529 (9-2023)

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All items in this section MUST be VERIFIED

Frequency: Is this expense ongoing?

• If no, answer one-time.

• If yes, answer weekly, bi-weekly, semi-monthly, monthly, quarterly, annually or other.

Type of Expense Who is Expense For Amount Paid Date Paid Frequency

Other (explain)

EXPENSES

Certain expenses paid may be deducted from your gross income.

Attach another sheet if need more space to answer the question below.

Check the type of expense(s) the household members have paid since June 1 and list the details below.

Child Care (not reimbursed by anyone) Child Support Spousal Support

Court Ordered Garnishments Representative Payee Medical Prescriptions

Medical Expenses Health and Hospitalization Insurance Premiums

Have you received or intend to receive reimbursement for any of these medical expenses from insurance or from the Veteran's

Administration?

Yes No

HOUSING

Type of Home

House

Mobile Home Apartment Building (3 or more units) Duplex (2 units)

Does your furnace heat other units?

Yes No

Is the living unit a split level?

Yes No

Number of Bedrooms:

Main Floor Upstairs Floor Basement

Split level: “split foyer” or “raised ranch” style homes generally have 4-5

feet of the lower level above ground level and exposed to the outside air.

Rent Status:

Do you?

Own Rent

IF you RENT, attach a copy of your lease and your most recent rent receipt.

Renters:

Renters whose heating costs are included as an undesignated portion of their rent payment and are not on low-income housing

assistance or live in subsidized housing will receive a monthly LIHEAP renter payment during the LIHEAP heating season, generally

mailed out the third Thursday of each month.

Does your rent include the cost of heating?

Yes - My rent includes the cost of my heat.

No - My rent does not include the cost of my heat, as I am responsible to pay the heat bills.

SFN 529 (9-2023)

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Landlord's Name

Landlord's Telephone Number

Amount of rent you pay

Low-income housing assistance/subsidized housing is when your rent is partially paid by an outside group.

Do you receive any low-income housing assistance or have subsidized rent?

Yes No

HEATING (Attach a copy of your most recent heating bill)

Primary Heat Source:

What is your primary type of heat?

Natural Gas Electricity Propane Fuel Oil Coal Other

Using non-installed appliances such as space heaters or electric fireplaces are not an allowable source of heat. If your furnace runs on

natural gas, fuel oil or propane and is powered by electricity, then electricity is not your primary source of heat. Select natural gas, fuel

oil, or propane as your primary source of heat.

Renters: Contact your landlord if you do not know the type of heat your home uses.

Besides providing heat for your house, does this source provide fuel and/or

power for any other buildings, machinery, vehicles or any other uses?

Yes

If YES, Explain

Automatic Payments (auto pay): the vendor automatically withdraws your monthly payment from your bank account.

Are you currently on auto pay?

If YES, do you want LIHEAP to pay your vendor while on autopay?

Yes No

Have you recently received a shut-off notice?

Yes No

If YES, Shut-Off Date

Do you need fuel immediately?

Yes No

If YES, Approximate Remaining Quantity

Name of Primary Heating Supplier City

Name on Primary Heating Account Account Number on Primary Heating Bill

YES, I would like LIHEAP to pay my vendor. I am aware if my vendor has not received my LIHEAP payment they may pull the

money from my bank account to pay my bill. Once the vendor receives the LIHEAP payment, the LIHEAP payment will be applied to

my account with my vendor.

NO, I would like to continue to pay my bill each month and turn my paid bills in each month to the county office for reimbursement.

Secondary Heat Source:

LIHEAP may pay for a secondary heat source if it is used in a primary living space, such as a bedroom that is in use, a

kitchen, a living room, or a family room. Using non-installed appliances such as space heaters or electric fireplaces are not

an allowable source of heat. If your furnace runs on natural gas, fuel oil or propane and is powered by electricity, then

electricity is not your source of heat. Example: baseboard heat is an example of a secondary electric heat source.

Do you have a qualified secondary heating supplier?

Yes

If YES, what type?

Natural Gas Electricity Propane

Fuel Oil

Coal Other

Name of Secondary Heating Supplier City

Name on Secondary Heating Account Account Number on Secondary Heating Bill

Utility Vendor (lights): Same as

Primary vendor or Secondary vendor as listed above or Lights vendor below

Name of Utility Vendor City

Name on Utility Account Account Number on Utility Bill

SFN 529 (9-2023)

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PRIOR MONTHS' ELIGIBILITY AND REIMBURSEMENTS

LIHEAP may go back to determine eligibility for months prior to your application date within the current heating season.

Each new heating season starts October 1. LIHEAP can assist with unpaid bills or reimburse you on the bills you have paid.

YOU MUST PROVIDE VERIFICATION of your income, heating bill, and proof of payment (for reimbursement) for any

months you are requesting assistance.

Please check the back months you are requesting assistance:

October November December January February March April

Please check the back months you have paid in full and are requesting reimbursement:

October November December January February March April

WEATHERIZATION AND OTHER SERVICES

If approved, your signature on this application will permit the Community Action Agency in your area to contact you about

weatherization. To prevent a heating crisis and promote safety and energy conservation the following services are

available. If approved for LIHEAP and interested in weatherization, contact your local Community Action Agency.

• Weatherization services can help you save money on your energy costs with no cost or obligation to you.

• Self-Reliance Program can help you with budget counseling.

• Energy Share can help you with non- heat utility bills in emergency situations.

• Furnace/Chimney cleaning can help you with the cost to clean and tune your furnace/chimney. See the LIHEAP

brochure for price limits and eligibility.

FURNACE / CHIMNEY CLEANING

The eligibility worker will not be able to choose the vendor. Please contact the Customer Support Center if you need a list of

vendors in your area.

Would you like to have your furnace cleaned?

Yes No

If YES, Specify Furnace Vendor

Would you like to have your chimney cleaned?

Yes No

If YES, Specify Chimney Vendor

APPLICATIONS RECEIVED JUNE 1 - SEPTEMBER 30

What are you applying for since the heating season (October 1 - May 31) has ended?

Cooling Assistance can assist with a cooling device (an air conditioner or a fan, as the need dictates), if a member of

the household is elderly (60 years of age or older) or has a documented medical need and is income eligible for

LIHEAP. Cooling Assistance does not cover the cost to cool your home, it only covers the cost of the cooling device.

Emergency Home Energy Assistance can assist a household, when there is a home emergency that may threaten

the life of your family. You will also need to complete SFN 62, LIHEAP Emergency Application.

YOUR RIGHT TO APPEAL

You have the right to appeal and request a fair hearing if you disagree with any decision made on your Heating Assistance

or Emergency Assistance application, or if you do not receive a written notice of the action taken on your Heating Assistance

application within 45 days from the date your application is received. Your written request for a hearing must be received

within 30 days of the date of the notice of action. Contact your Customer Support Center for instructions on how to

request an appeal or fair hearing.

NON-DISCRIMINATION POLICY

In accordance with Federal law, the U.S. Department of Health and Human Services (US HHS) policy, and North Dakota

state law, HHS is prohibited from discriminating on the basis of race, color, sex, including gender identity and sexual

orientation, age, disability, national origin, religion, or status with respect to marriage or public assistance. In accordance

with the USDA, HHS is also prohibited from discriminating against political beliefs or reprisal or retaliation for prior civil rights

activity in any program or activity conducted or funded by the USDA. A written complaint may be filed with your local

Human Service Zone Office; or the Legal Division, Department of Health & Human Services, 600 E. Boulevard Ave -

Dept 325, Bismarck ND 58505-0250; Phone: 701-328-2311; TTY 711; Fax: 701-328-2173; Email: [email protected]; or

*Centralized Case Management Operations, *U.S. Department of Health & Human Services, 200 Independence Ave

SW, Room 509F HHH Bldg, Washington DC 20201; Toll-free: 1-800-368-1019; TTY: 1-800-537-7697; Fax: 202-619-3437;

Email: [email protected]; or *U.S. Department of Health & Human Services, Office for Civil Rights, Region VIII,

1961 Stout Street, Room 1185, Denver, CO 80294-3538; Toll-Free: 1-800-368-1019; TDD: 1-800-537-7697; FAX: (202)

619-3818; Email: [email protected].

*State and local agencies are required to comply with North Dakota Human Rights Law that prohibit discrimination based on

"status with respect to marriage or public assistance." Federal agencies are not required to investigate complaints based on

North Dakota Human Rights Laws.

A Civil Rights Complaint form (SFN 143) is also available in a pdf format at:

https://www.nd.gov/eforms/Doc/sfn00143.pdf

SFN 529 (9-2023)

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READ, SIGN AND DATE THE APPLICATION

I certify that the information given above is true, correct and complete to the best of my knowledge. I understand that

knowingly giving false information may result in a fine, imprisonment or both, and that I must pay back any benefits received

as a result of giving wrong information. I agree to notify the Customer Support Center whenever I have changes that were

mentioned in the household reporting requirements section, and to refund upon request the value of unused fuel purchased

by LIHEAP.

I acknowledge that I have read the information regarding non-discrimination.

Signature

Date

Signature

Date

Worker Signature

Date

Community Options (if applicable)

LIHEAP Outreach Worker Name

Date

Location

I understand that by checking this box and typing my name, I am signing this SFN 529 application.

I agree that my electronic signature is the legal equivalent of my handwritten signature.

I/We authorize:

• this agency to verify information affecting my/our energy assistance eligibility and benefits;

• any person having custody or knowledge of the information relating to me or other household members to

disclose any requested information, including confidential information other than protected health information, to

any authorized agent to the Department of Health and Human Services;

• Child Support to release any records of any child support payment that I/we have made or received;

• my/our heating and electric vendors to give data about my/our account, usage and billing information to the

Department of Health and Human Services (HHS), Human Service Zone offices and HHS contractors for the

Energy Assistance Program, Weatherization Program, and Federal reporting.

• LIHEAP, Health and Human Services Zone Office(s), Community Action, Community Options and Energy

Share, to verify and share information affecting my eligibility and benefits.

Return your signed and dated application to your local human service zone office

Submit by mail to:

Department of Health and Human Services

Customer Support Center

PO Box 5562

Bismarck ND, 58506

OR FAX: (701)-328-1006

OR Email: [email protected]

For questions call Customer Support Center at: 1-866-614-6005

Human service zone office locations can be found here: https://www.hhs.nd.gov/human-service/zones

THIS APPLICATION WILL BE PROVIDED IN AN ALTERNATE FORMAT UPON REQUEST.

HOUSEHOLD REPORTING REQUIREMENTS

Report and provide verifications of these changes within 10 days of the date they occur to the Customer Support Center.

Failure to report timely may cause an overpayment and case closure.

Report if:

• you move to a different home

• you change your type of heat

• there is loss or addition of persons living with you

• your low-income housing assistance/rent subsidy status changes (starts or ends)