AEO-9495 (R 10/2021) 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
Name of Primary Heating Supplier::
☐ Propane, Butane, or LPG
If your heating bill is not in your name, whose name is the account in?
Does this person live with you?
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::
☐ Propane, Butane, or LPG
If your heating bill is not in your name, whose name is the account in?
Does this person live with you?
What is this person’s relationship to you?
Name of Electric Supplier:
If your electric bill is not in your name, whose name is the account in?
Does this person live with you?
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:
Arkansas Driver’s License
Federal, state, or local government issued ID Card
U.S. Military Card or dependent’s card
ID card for health benefits or other assistance
Work or school ID card with photograph
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 that 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 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
Witness, if signed by mark
Signature of Person Helping To Complete this Form
click to sign
signature
click to edit
click to sign
signature
click to edit