Fill - Free fillable Applicaon for Financial Help to Heat or Cool (Missouri) PDF form

How to apply for LIHEAP

 





 



When to apply for LIHEAP

• Send your applicaon to arrive October 1st or aer if: 





• Send your applicaon to arrive November 1st or aer if: 



Aer you send your applicaon



 

 





Important:

 



 





FAMILY SUPPORT DIVISION

Missouri Department of Social Services

Applicaon for Financial Help to Heat or Cool Your Home



Agency Use Only



Part 1 – Contact Informaon/Address Correcons









   

   



Email

 

Part 2 – Household Members







 

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Part 2 – Household Members (connued)

Food Social

U.S.

Sex Birth Disabled? Relaonship

Name Stamps? Security

Race Cizen?

M/F Date Yes/No to You

Yes/No Number

Yes/No

SELF

Part 3 – Ulity/Household Informaon

• All applicants: 



• Applicants whose heat has been disconnected or may be disconnected soon:

 

 





.............................................

 No

 .......................  No

......................................................................  No

 ......................  No







not



What primary (main) form of energy heats your home?

      

  No





 No





 

 

 

Part 4 – If You Don’t Pay the Ulity Company Directly



  No

  No

  No

  No

 



Part 5 – Income You Earn or Pay For Child Support



 



 





List everyone in your home age 18 or older who received income from a job last month. (Include all jobs.)

Name Employer How Oen Paid? Gross Pay

Sll Employed?



 No

If yes, send a copy of the most recent Federal Income Tax Form 1040, including Schedule 1, for each self-employed

person along with your applicaon.

 

What secondary (other) form of energy heats your home? (Required to provide your electric supplier if your PRIMARY

(MAIN) supplier is Natural Gas or Tank Propane)

  No





 No



 

 

Part 6 – Income That Isn’t Earned



 

 

AMOUNT HOW OFTEN

SOURCES OF INCOME WHO RECEIVES THIS INCOME?

RECEIVED RECEIVED?



















































 





  No

 



Part 8 – Noce That You Can Get a Fair Hearing – For informaonal purposes only





 

 



Papers you must send with your applicaon to avoid processing delays (send copies, originals will not be returned):









Papers you need to send if any member of your household got any income last month:









Part 9 – Your Consent for the LIHEAP Agency to Process (Review) This Applicaon

If you do not sign and date the applicaon, your LIHEAP

applicaon will not be processed.



I realize that the

informaon which I have given on this applicaon will need to be veried by the LIHEAP agency.















I understand that an electronic signature has the same legal eect and can be enforced in the same way as a wrien

signature.

Signature Date

 

Part 7 – Savings and Other Accounts





Type How Much? Type How Much?













Submit

WHERE TO SEND YOUR LIHEAP APPLICATION

Search for your local office by referring to the county in which you live.

Audrain, Boone, Callaway, Cole, Cooper, Howard,

Moniteau, Osage

Central Missouri Community Action (CMCA)

800 N Providence Rd Ste 200

Columbia, MO 65203-4300

Phone number: (573) 443-1100 Fax (573) 370-1212

St. Louis County

Community Action Agency of St. Louis County (CAASTLC)

2709 Woodson Rd

Overland, MO 63114-4817

Phone number: (314) 446-4420 Fax (314) 446-4480

Andrew, Buchanan, Clinton, DeKalb

Community Action Partnership of Greater St. Joseph

(CAPSTJOE)

817 Monterey

St. Joseph, MO 64503-3611

Phone number: (816) 233-8281 Fax (816) 233-8262

Atchison, Gentry, Holt, Nodaway, Worth

Community Services, Inc. of Northwest Missouri (CSI)

PO Box 328

Maryville, MO 64468-0328

Phone number: (660) 582-3113 Fax (660) 582-2965

Barton, Jasper, Newton, McDonald

Economic Security Corporation of Southwest Area (ESC)

PO Box 207

Joplin, MO 64802-0207

Phone number: (417) 781-0352 Fax (417) 781-2011

Bollinger, Cape Girardeau, Iron, Madison, Perry, St.

Francois, St. Genevieve, Washington

East Missouri Action Agency (EMAA)

PO Box 308

Park Hills, MO 63601-0308

Phone number: (800) 392-8663 Fax (573) 431-7377

Dunklin, Mississippi, New Madrid, Pemiscot, Scott,

Stoddard

Delta Area Economic Opportunity Corporation (DAEOC)

99 Skyview Rd

Portageville, MO 63873-9180

Phone number: (573) 379-3851 Fax (573) 379-9139

Caldwell, Daviess, Grundy, Harrison, Linn, Livingston,

Mercer, Putnam, Sullivan

Community Action Partnership North Central Missouri

(CAPNCM)

1506 Oklahoma Ave

Trenton, MO 64683-2587

Phone number: (660) 359-3907 Fax (660) 359-2038

City of St. Louis, Wellston

Urban League (ULSTL)

3701 Grandel Square

St. Louis, MO 63108-3627

Phone number: (314) 615-3632 Fax (314) 531-7462

Jefferson, Franklin

Jefferson-Franklin Community Action Corporation (JFCAC)

PO Box 920

Hillsboro, MO 63050-0920

Phone number: (636) 789-2686 Fax (636) 789-2866

Camden, Crawford, Gasconade, Laclede, Maries, Miller,

Phelps, Pulaski

Missouri Ozarks Community Action, Inc. (MOCA)

PO Box 69

Richland, MO 65556-0069

Phone number: (573) 765-3263 Fax (573) 765-0026

Carroll, Chariton, Johnson, Lafayette, Pettis, Ray, Saline

Missouri Valley Community Action Agency (MVCAA)

1415 S Odell Ave

Marshall, MO 65340-3144

Phone number: (660) 831-5331 Fax (660) 831-5039

Lewis, Lincoln, Macon, Marion, Monroe, Montgomery,

Pike, Ralls, Randolph, Shelby, St. Charles, Warren

North East Community Action Corporation (NECAC)

805 Business Highway 61 N

Bowling Green, MO 63334-1351

Phone number: (573) 324-0120 Fax (573) 213-4858

Adair, Clark, Knox, Schuyler, Scotland

Community Action Partnership North East Missouri

(CAPNEMO)

PO Box 966

Kirksville, MO 63501-0966

Phone number: (660) 665-9855 Fax (660) 665-6557

Douglas, Howell, Oregon, Ozark, Texas, Wright

Ozark Action, Inc. (OAI)

710 E Main St

West Plains, MO 65775-3307

Phone number: (417) 256-6147 Fax (417) 256-0333

Barry, Christian, Dade, Dallas, Greene, Lawrence, Polk,

Stone, Taney, Webster

Ozarks Area Community Action Corporation (OACAC)

215 S Barnes Ave

Springfield, MO 65802-2204

Phone number: (417) 864-3460 Fax (417) 864-3472

Butler, Carter, Dent, Reynolds, Ripley, Shannon, Wayne

South Central Missouri Community Action Agency (SCMCAA)

PO Box 6

Winona, MO 65588-0006

Phone number: (800) 325-4633 Fax (573) 325-4543

Jackson, Clay, Platte

Mid America Assistance Coalition (MAAC)

4001 Blue Parkway, Suite 270

Kansas City, MO 64130-2350

Phone number: (816) 768-8900 Fax (816) 768-8901

Bates, Benton, Cass, Cedar, Henry, Hickory, Morgan, St.

Clair, Vernon

West Central Missouri Community Action Agency (WCMCAA)

106 W 4

Street

Appleton City, MO 64724-1402

Phone number (660) 476-2185 Fax (660) 476-5901

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Applicaon for Financial Help to Heat or Cool (Missouri)

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