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HSEA 1 7/20
Apply online at www.compass.state.pa.us
Yes
No
Is anyone in the U.S. Military or has anyone been in the U.S. Military?
If yes, who?
15
Yes
No
Is anyone a widow, spouse or child (under age 18) of anyone in the U.S. Military or anyone
who has been in the U.S. Military?
If yes, who?
Yes
No
13
Yes
No
Are you or anyone in your household fleeing to avoid prosecution or custody for a
crime, or an attempt to commit a crime that would be classified as a felony?
If yes, who?
14
Are you interested in free weatherization service? Weatherization services include home
insulation and heating system evaluation.
Name of person with income Type/source of income Start Date Date of First Paycheck How much each month?
Name of person with income Type/source of income Start Date Date of First Paycheck How much each month?
Name of person with income Type/source of income Start Date Date of First Paycheck How much each month?
Name of person with income Type/source of income Start Date Date of First Paycheck How much each month?
12
Using income on file for someone? You don’t need to list them or their income in question 12.
Tell us about income for the people in your household.
Please tell us about all income, before taxes and deductions. Types/
sources of
income include money from: Employment, Veteran’s Benefits, Unemployment Compensation, Black Lung benefits,
Social Security, Support, Workers Compensation, Interest/Dividends, Rental Income. See “Did you remember to...” on page 4.
1. My signature on this application gives my permission to the
Department of Human Services or its authorized agent to:
(a) check any information I give about where I live, my jobs, income,
resources, energy supply and energy supplier; (b) share information
with my energy supplier and receive information from my energy
supplier to allow DHS to obtain a record of my annual energy
consumption, cost and billing information for purposes of program
evaluation, operation, or reporting; and (c) complete any survey in
connection with energy assistance.
2. Furnishing this information (including your SSN) is voluntary;
however, failure to furnish the requested information may delay
or prevent the completion of your application or delay or prevent
your ability to receive benefits. If you fail to provide a SSN or fail to
complete the information below, you may be ineligible for benefits.
I certify that: (check all that apply)
o
I provided Social Security numbers for all household
members.
o
To the best of my knowledge, these household members do
not have Social Security numbers:
o
The following household members are exercising their rights
under Section 7 of the Privacy Act of 1974, and refuse to
disclose their Social Security Number or may be unable to
because they are a victim of domestic violence:
3. I authorize the release of LIHEAP eligibility information to and from
my energy suppliers or weatherization agencies and allow them to
seek assistance for which I may be eligible. The assistance may
include LIHEAP Cash, Crisis, or Weatherization benefits.
4. I understand I have the right to appeal any decision or undue delay in
decision which I consider improper regarding this application.
5. I affirm that Pennsylvania is my legal residence.
6. I understand any Social Security number(s) given will be used in the
administration of this program, including cross matches with other
programs.
7. I understand that I will be sent a notice of eligibility or ineligibility and, if
eligible, the notice will state the amount of my benefit.
8. I further understand that if my household is eligible for a LIHEAP cash
benefit, it must be sent directly to my utility company or fuel dealer unless I
am a renter and my heat is included in my rent or my fuel is supplied by a
fuel dealer who does not accept vendor payment.
9. I certify that, subject to penalties provided by law, the information I gave
is true, correct and complete to the best of my knowledge.
10. I know that if I give false information, I can be penalized by fine and/or
imprisonment.
11. I understand by signing this application, I may not qualify because
LIHEAP money has run out.
12. If your household is eligible for LIHEAP, you may receive a Fast Track
consent form in the mail that could allow you and your household
members to be automatically enrolled in Medical Assistance.
Please Sign Here - Use Ink
Signature Date
Certification
Print Name Print Name
Print Name Print Name
X
Privacy Act Notice; Authority: 42 U.S.C. § 405(c)(2)(C)(i) authorizes the collection of this information.
Purpose: The Department of Human Services (“DHS”) will use this information to identify and verify
income of applicant(s).
Routine Uses: The information will be used by and disclosed to DHS personnel and contractors or
other agents who need the information for LIHEAP administration. Additionally, DHS may share the
information with other government agencies or in reports to legislative representatives as required by
federal or Pennsylvania law.
