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AEO-9495 (R 10/20) Page 1 of 4
ARKANSAS ENERGY OFFICE
ARKANSAS HOME ENERGY ASSISTANCE PROGRAM
APPLICATION
If you need this material in a different format, such as large print,
CONTACT YOUR LOCAL COMMUNITY ACTION AGENCY (CAA)
FO R A G E N C Y U S E O N L Y
R E G I S T E R N U M B E R ( S )
APPLICATION DATE
REGULAR ASSISTANCE
APPLICATION TIME
CRISIS INTERVENTION
a.m.
p.m.
DISPOSITION TIME LIMIT
SUPPLEMENTAL
☐18 HOURS
☐ 48 HOURS
Interviewer
Method
Date
You must apply through the CAA serving the county in which you live.
Complete all sections and attach requested documentation; failure to do so will delay
processing of your application.
TO MAKE CHANGES, DO NOT WHITE OUT. CROSS-OUT AND RE-WRITE ANSWER.
Affordable Care Act (ACA) – The comprehensive health care reform law was enacted in March 2010. The law has 3 primary goals:
(1) Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that
lower costs for households with incomes between 100% and 400% of the federal poverty levels; (2) Expand the Medicaid program to cover
all adults 19 – 64 years of age with income below 100% of the federal poverty level; and (3) Support innovative medical care delivery
methods designed to lower the costs of health care generally.
FOR MORE INFORMATION GO TO HEALTHCARE.GOV OR CALL 1-800-318-2596
What bill(s) do you need assistance with? (Check up to Two.)
☐ Gas
☐ Electricity
☐ Propane
☐ Fuel Oil
☐ Other:
1. APPLICANT – PLEASE PUT YOUR NAME AND INFORMATION HERE
attach copy of ID (e.g., driver’s license) and Social Security card
Last Name
First Name
Middle Name
Mailing Address
City
State
Zip Code
Street Address if different from mailing address
City
State
Zip Code
County of Residence
Mobile Phone Number
Home Phone Number
Email Address
Social Security Number
Date of Birth
Age
Do you have a Disability?
☐ Yes ☐ No
Gender
Race
☐ Male ☐ Female ☐ Other
☐ White ☐ Black ☐ Spanish American/Hispanic ☐ Oriental; Asian or Pacific Islander
☐ Native American or Alaskan Native ☐ Other ☐ Unknown
2. OTHER HOUSEHOLD MEMBERS – DO NOT INCLUDE YOURSELF
Please list the other persons living in your household but not yourself. Please complete all items. (Please list additional members on a separate sheet).
NAME
RELATIONSHIP TO YOU
DATE OF BIRTH
AGE
RACE
SOCIAL SECURITY
NUMBER
DISABLED?
YES NO
1.
2.
3.
4.
5.
6.
AEO-9495 (R 10/20) Page 2 of 4
3. HOUSEHOLD INCOME
A. WORK INCOME - List anyone in your household who has work income (Includes self-employment, babysitting; et cetera)
YOU MUST ATTACH COPIES OF LAST MONTH’S PAY STUBS
WHO IS EMPLOYED
HOW OFTEN PAID
GROSS AMOUNT
LAST MONTH
EMPLOYER NAME
1.
2.
3.
B. LAST EMPLOYMENT – If you or any adult (18 or older) member of your household is unemployed at the time of the application, list your
most recent employment below.
NAME
WHERE LAST EMPLOYED
WHEN EMPLOYMENT ENDED
1.
2.
3.
C. NON-WORK INCOME – List anyone in your household who receives any of the following and attach proof of this income:
Child Support, Social Security Income; (SSA) Supplemental Security Income (SSI); Supplemental Security Disability Income (SSDI); TEA; Alimony;
Unemployment benefits; Worker’s Compensation; Veterans Benefits; Retirement Benefits; Housing Utility Assistance Payment; any other non-work income:
WHO RECEIVES IT?
HOW OFTEN PAID
GROSS MONTHLY AMOUNT
NON-WORK INCOME FROM
(SSA, RETIREMENT, ETC.)
1.
2.
3.
RESOURCES Does anyone in your home have any of the following?
D. –
RESOURCES
YES
NO
AMOUNT
WHERE
NAME(S) OF PERSON
Cash on hand
Checking Account
Other Bank Accounts
Other Resources (list)
Other Resources (list)
If your household is in need of crisis assistance, please indicate below:
CRISIS APPLICANTS ONLY:
☐ I have a past due balance on a utility bill.
☐ HEATING
☐ ELECTRICITY
☐ My home energy utility has been disconnected.
☐ HEATING
☐ ELECTRICITY
☐ I have received notice that my home energy utility will be disconnected.
☐ HEATING
☐ ELECTRICITY
☐ My heating fuel is at or below 10% of the tank capacity and the fuel supplier will not deliver additional fuel without payment.
☐ I have 3 weeks’ supply or less heating fuel (wood, coal, or other heating fuel not kept in a tank) and the fuel supplier will not deliver
additional fuel without payment.
☐ I have received an eviction notice which is partly due to my failure to pay my heating and/or electricity expenses to my landlord.
☐ I need assistance to pay a deposit to have my utility connected/reconnected:
☐ HEATING
☐ ELECTRICITY
Is your crisis situation life-threatening?
☐ YES ☐ NO
If yes, please explain in detail.
4. UTILITY/RENT INFORMATION
Do you
☐ Rent or
☐ Own your home?
RENTERS ONLY –
Is your energy cost included in your rent payment?
☐ YES ☐ NO
If yes, attach a copy of your lease that says utilities are included in your rent and provide:
Landlord.
LANDLORD’S NAME
LANDLORD’S PHONE
✔
AEO-9495 (R 10/20) Page 3 of 4
5. HOME ENERGY SUPPLIER INFORMATION
You must complete information on BOTH – PRIMARY Heating Source AND ELECTRIC – AND include copies of EACH bill.
My residence is ALL ELECTRIC
☐ YES ☐ NO
Name of Primary Heating Supplier::
Account Number:
☐ Natural Gas
☐ Electricity
☐ Fuel oil or kerosene
☐ Propane, Butane, or LPG
☐ Other:
If your heating bill is not in your name, whose name is the account in?
Is the account closed?
☐ YES ☐ NO
Does this person live with you?
☐ YES ☐ NO
What is this person’s relationship to you?
SECONDARY HEATING SUPPLIER IS OPTIONAL, COMPLETE ONLY IF YOU WANT ASSISTANCE WITH THIS BILL.
Name of Secondary Heating Supplier::
Account Number:
☐ Natural Gas
☐ Electricity
☐ Fuel oil or kerosene
☐ Propane, Butane, or LPG
☐ Other:
If your heating bill is not in your name, whose name is the account in?
Is the account closed?
☐ YES ☐ NO
Does this person live with you?
☐ YES ☐ NO
What is this person’s relationship to you?
Name of Electric Supplier:
Account Number:
Is the account closed?
☐ YES ☐ NO
If your electric bill is not in your name, whose name is the account in?
Does this person live with you?
☐ YES ☐ NO
What is this person’s relationship to you?
6. VERIFICATION OF IDENTITY (ID)
You must attach proof of identity. Acceptable proof includes A READABLE COPY of any VALID document that reasonably establishes
identity such as:
Driver's license or ID Card issued by a State or federal possession
Federal, state, or local government issued ID Card U.S. Military Card or dependent’s card
Voter registration card
ID card for health benefits or other assistance Work or school ID card with photograph
A recent
paycheck stub
7. WEATHERIZATION SERVICES (WAP)
Would you like to be referred for home Weatherization? ☐ YES ☐ NO
If yes, may LIHEAP send your application to WAP? ☐ YES ☐ NO
8. APPLICANT’S RIGHTS AND RESPONSIBILITIES
FAILURE TO SIGN AND DATE A PAPER APPLICATION WILL DELAY THE PROCESSING OF YOUR LIHEAP APPLICATION.
I understand that I have the right to appeal any decision regarding this application which I consider improper, and also any delay in decision
or delivery of services.
I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.
I authorize the contracted agency to release information relating to my application for LIHEAP to my Energy Supplier(s) to determine
eligibility. I give permission to the Arkansas Energy Office (AEO) to use information provided on this form for purposes of research,
evaluation and analysis of the program.
I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be responsible
for monitoring or taking any steps to ensure that the LIHEAP office maintains the confidentiality of the data or uses the data as I have
authorized.
I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political
belief.
I understand that my signature on this application authorizes the agency to make any investigation concerning me or any household member
and/or use a copy as a release of information for securing information needed to determine my eligibility for services.
I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or
fraudulent information regarding my circumstances, I must repay the cost of any assistance and may face penalty of criminal prosecution.
The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to
penalties for perjury.
Signature of Applicant (must be same person listed in
Section 1, page 1) or Authorized Representative
Date
Witness, if signed by mark
Date
Signature of Person Helping To Complete this Form
Date
Address of Witness
Date
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signature
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AEO-9495 (R 10/20) Page 4 of 4
FOR AGENCY USE ONLY
1. CRISIS SITUATION: Verification must be attached
2. CIP BENEFIT COMPUTATION:
☐ Past due balance on bill
☐ Notice of imminent disconnection
a. Minimum amount necessary to alleviate crisis
situation?
$
☐ Disconnected ☐ Eviction Notice
b. Amount of Regular Assistance Available?
$
☐ 10% or less of tank capacity and supplier refused delivery
c. Net amount necessary?
$
☐ Other (specify)
d. CIP available?
$
e. Supplemental Available?
$
MINIMUM AMOUNT REQUIRED
f. Additional amount necessary
$
a. Past due for energy
$
g. If f. is more than $0, explain how the household or other
source will furnish the additional amount necessary.
b. Connection fee
$
c. Reconnection fee
$
d. Deposit
$
e. Minimum delivery
$
f. Tank rental
$
g. Other (specify)
$
h. Total amount needed
$
COMMENTS:
B. DISPOSITION
☐ Regular ☐ Crisis ☐ SUPPL
1. Previous Application ☐ YES ☐ NO
Register #
2. ☐ Confirmed that the household has not been approved for
Regular or Crisis program.
DATE:
HH SIZE:
3. ☐ Approved ☐ Denial ☐ Withdrawn
WORKER:
4. Disposition Date:
A. BUDGET:
1. Income Month
Regular:
CIP
SUPPL
☐ Month of Application
5. Benefit Amount:
☐ Month prior to application
Regular:
CIP
SUPPL
2. Total GROSS: (Earned Income)
$
C. PAYMENT
☐ Regular ☐ Crisis ☐ SUPPL
1. Payee
Supplier
3. NET (Earned Income) 80% Gross
$
Supplier
Supplier
Applicant
4. Unearned Income
2. Assistance provided (Crisis only)
Social Security
$
☐ Payment ☐ Verbal Obligation ☐ Specify
Supplemental Security Income (SSI)
$
Trans. Employment Asst. (TEA)
$
Date:
Time:
☐ a.m. ☐ p.m.
Veterans Affairs (V A) Benefits
$
3. Payment Date:
Check #:
4. Payment Date:
Check #:
5. Payment Date:
Check #:
Other
$
6. Service Restored
☐ YES ☐ NO
7. Loss of Service Prevented
☐ YES ☐ NO
5. Total Unearned Income
$
D. WEATHERIZATION REFERRAL
6. Monthly Countable Income (3 & 5)
Application was referred:
☐ YES ☐ NO
$
If no, why?
Applicant is an Agency Employee or Family Member?
☐ YES ☐ NO
Executive Director’s Signature:
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