Miami Dade Community Action Agency
Low Income Home Energy Assistance Program
LIHEAP APPLICATION
For Office Use Only |
Did you remember to attach COPIES of the following ? |
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Home Energy |
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] SS cards for all household members |
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Crisis |
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] Proof of income for all household members (past month) |
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Disaster Assistance |
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Copy of identification for applicant only |
Stamp Date to the Right |
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Copy and original of most recent energy bill |
PLEASE FILL OUT APPLICATION COMPLETELY
Your LIHEAP application is not a commitment that your bill will be paid. If eligible, a credit will be sent directly to the utility vendor. However:
You must continue to pay the amount owed on your bill.
1.Give the following information for yourself first and then each person living in your home. If more than six persons live in your home, list the additional persons, giving the same information on a separate sheet of paper and attach to this form.
Marital status: ________________ Place of birth: ________________ |
Ethnicity: ________________ Citizenship: _______________ |
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Name |
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Date of |
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Relationship |
Education |
Source of |
Monthly |
First, Middle, Last |
Social Security Number |
Birth |
Age |
Sex |
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Race |
to applicant |
Completed |
Income |
Income |
(Applicant Name) |
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SELF |
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Page 1 of 4
LIHEAP ASSISTANCE APPLICATION |
Page 2 of 4 |
2.The address where you are living:
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__________________________________________________________ |
___________, FL |
__________ |
______________________ |
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Street Number and Name, RFD, Apt. or Lot No. |
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City or Town |
Zip Code |
County |
3. |
Your mailing address, if different from above: |
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__________________________________________________________ |
___________, FL |
__________ |
______________________ |
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Street Number and Name, RFD, Apt. or Lot No. |
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City or Town |
Zip Code |
County |
4. |
Day time telephone number where you can be reached: ( |
) _________________________ |
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) __________________________ |
5.If your monthly household income is less than $738 per month, explain how you pay for food, shelter, clothing, transportation and home utilities.
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
6.Complete the following for your household:
Number of elderly persons (65 or older) |
#___________ |
Number of disabled persons |
#___________ |
Number of children 5 years of age or younger |
#___________ |
7.If you share your living or mailing address with others who are not part of your home, list their names:
_______________________________________; __________________________________; ___________________________________
8.If you or anyone in your home are not a U.S. citizen or an alien lawfully admitted for permanent residence, give the person’s name and alien status under the Immigration and Naturalization Act.
Name: _________________________________________________ Alien Status: _____________________________________________
9. |
Are you or any member of your household a member of the Porch Creek Indian Tribe? Yes ______ |
No _______ |
LIHEAP ASSISTANCE APPLICATION |
Page 3 of 4 |
10.Check the programs that anyone in your household is currently eligible for or receiving assistance from:
_____CSBG |
_____Weatherization |
_____TANF/WAGES |
_____Food Stamps |
_____None |
11.If you or any member of your household has received energy assistance in the last 13 months, complete the information below:
_____________________________________________ |
_____________________________________ |
_____________________ |
Name of Agency |
Type of help (elderly, crisis, emergency) |
Date |
12.Do any of the following situations currently apply to you? (Check appropriate box(es) below)
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My electricity has been disconnected. |
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My current electric bill is delinquent. |
[] I have a shut-off notice from the electric company.
[] None of the above currently apply to my household.
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I have little or no propone, fuel oil or wood for heating. |
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I have a shut-off notice from my gas company. |
[] My current natural gas bill is delinquent.
[] Other energy crisis-Describe:
________________________________________________________________________________________________________________
13.If your cost of home energy is included in your rent, give name and telephone number of your landlord. Attach a copy of a letter from the landlord confirming that your rent includes utilities.
Landlord: __________________________________________ |
Landlord’s Telephone Number ( ) ____________________________ |
14.If you live in government subsidized housing, Section 8 housing complex, a dormitory, nursing home, adult foster home, or any kind of group living facility, complete the following:
Name of place where you live: _____________________________________________________________________________________
__________________________________________________ |
________________,FL ________________ |
____________________ |
Street Number and Name, RFD, Apt. or Lot Number |
City or Town |
Zip Code |
Country |
LIHEAP ASSISTANCE APPLICATION
15.Provide the following information about the primary source of energy you use to heat your home. Give only one company.
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Customer’s Name on the |
Customer’s Account |
Company’s Telephone |
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Energy Source |
Company’s Name |
Account |
Number |
Number |
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Electric |
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Natural Gas |
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Propane |
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Fuel Oil |
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Wood |
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16. |
Provide the following information about the primary source of energy you use to cool your home. |
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Customer’s Name |
Customer’s Account |
Company’s Telephone |
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Energy Source |
Company’s Name |
on the Account |
Number |
Number |
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Air Conditioning |
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Fans |
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17.If not given above in questions 15 or 16 provide the following information about your electric company.
Customer’s Name on the
Account
Customer’s Account
Number
Company’s Telephone
Number
18.Attach a copy of your current bills for all companies listed above in questions 15, 16, and 17.
FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need, i.e. those households in which the elderly, disabled, medical needy or children reside. I authorize the agency to obtain and release confidential information on may behalf and to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if I am applying for crisis assistance, the agency has 48 hours; 18 hours if my situation is life threatening, to approve or deny my application, and, if I’m applying for Home Energy Assistance, the agency has 45 days to approve or deny my application. I am aware that the agency has 45 days to make a payment to my fuel supplier on my behalf. I’m also aware that if I am approved or denied within the time allowed, or not approved for the correct amount, I have to right to an appeals hearing.
I have received a copy of the Miami Dade County Notice of Privacy Practices.
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Return application to agency stamped below: |
_______________________________________ |
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Applicant’s Signature |
Date |
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______________________________________ |
________________ |
WEB APPLICATION |
Eligibility Worker Signature |
Date |
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_______________________________________ |
________________ |
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Supervisor/ Edit Staff |
Date |
Page 4 of 4 |