Fill - Free fillable Application for Financial Help to Heat or Cool PDF form

Missouri Department of Social Services

S D

Agency Use Only

AMILY UPPORT IVISION

Application for Financial Help to Heat or Cool Your Home

Date Stamp

Low Income Home Energy Assistance Program (LIHEAP)

How to apply for LIHEAP

1. Fill out the application below. For each section, read the instructions carefully, answer every question, and gather the

required documents (extra papers) you need to turn in with your application. If your application is not complete, it

could be delayed or turned down.

2. Send your completed application and extra papers to the LIHEAP agency that processes applications in the county you

live in. See “Where to Mail Your LIHEAP Application”. This is found on the last page of this application.

When to apply for LIHEAP

• Send your application to arrive October 1st or after if: Any member of your household is age 60 or over, or if any

household member is disabled. You may need to send extra papers with your application to show that your household

has someone age 60 or over, or who is disabled.

• Send your application to arrive November 1st or after if: Your household doesn’t include a person age 60 or over, or

who is disabled.

After you send your application

The LIHEAP agency will review your application and extra papers you provided:

• If your application is not considered a crisis, we’ll review it within 30 working days after we receive it.

• We’ll send you a letter by mail that tells if you qualify for LIHEAP and the amount you’ll get. The amount you are

approved for may be reduced if you owe the Missouri Department of Social Services, Family Support Division LIHEAP

any overpayments from previous years.

Important:

• Even after you apply for Energy Assistance, continue to pay your heating bill so you don’t get disconnected or run out

of bulk fuel such as propane, wood, or pre-paid electric.

• When you pay your heating or cooling bill, send it to the utility company that sent you the bill, not to the LIHEAP

agency. LIHEAP agencies will only process your application. They will never accept utility payments, fees, or co-

payments.

Part 1 – Contact Information/Address Corrections

Fill in your current home address or make any necessary corrections if the home address on the application is not current.

Also, if possible, please list a phone or message number so we can contact you if we have questions. This will help avoid

delays as we review your application. USE BLUE OR BLACK INK.

Name

Home Address City State Zip Code

Mailing Address (If different from home address) City State Zip Code

County of Residence Email Phone Number Cell Number

Part 2 – Household Members

List every person living in your household, starting with yourself. Fill in each box for every household member. If there are

more than 10 people living in your home, list the others on a separate sheet of paper. Must include all nine numbers of the

social security number and the month, day, and year of the birth date(s) for all household members.

MO 886-4576 (8-18) Page 1 of 5

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Part 2 – Household Members (continued)

Food Social U.S.

Sex Birth Disabled? Relationship

Name Stamps? Security Race Citizen?

M/F Date Yes/No to You

Yes/No Number Yes/No

SELF

Part 3 – Utility/Household Information

• All applicants: Fill in this section and send a copy of your most recent fuel statement and/or utility bill for both your

primary (main) heat source and your secondary (other) heat source.

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

• Send a copy of your disconnection notice along with the fuel statement or utility bill mentioned above, and

• If you or someone in your household suffers from a life threatening medical condition, send a medical statement from

a qualified doctor or nurse. The statement should say that the person has a life-threatening medical condition, but

does not have to state a diagnosis or condition.

Do you own your home or are you buying your home? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Yes No

Has your home been weatherized by the local agency weatherization program? . . . . . . . . . . . . . . . . . . . . . . . Yes No

Is your home all electric? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

Do you or a household member suffer from a life-threatening medical condition? . . . . . . . . . . . . . . . . . . . . . . Yes No

The type of furnace, wood stove, or heaters installed in your home determine what type of energy heats your home. For

example, if you have a natural gas furnace, your primary (main) heat source would be natural gas. Your secondary (other)

heat source would be electric because it’s used to run the furnace blower.

If your home is not all electric and your primary (main) energy supplier is Natural Gas or Tank Propane, you are required to

provide information about your electric supplier in the secondary (other) fields located below.

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

Natural Gas Tank Propane Electric Wood Cylinder Propane Fuel Oil Kerosene

Are you currently without a primary (main) heat source, because it got disconnected or you’re out of fuel? Yes No

Are you currently in threat of not having a primary (main) heat source, because it may be disconnected soon or you’re low

on fuel? Yes No

If you answered yes to either question, please fill in the disconnection date or how much wood, propane, or pre-paid

electric you have:

List your main heat supplier’s name City

Whose name appears on the account? Account Number

MO 886-4576 (8-18) Page 2 of 5

Part 4 – If You Don’t Pay the Utility Company Directly

Fill in this section if you don’t pay your heating or cooling bill directly to the utility company.

The account is in my Landlord’s name and I pay my Landlord for my heating. Yes

I live in subsidized housing or receive Section 8. Yes No

Heating costs are included in my rent. Yes No

Cooling costs are included in my rent. Yes

Num er

Landlord’s Name Phone b

Landlord’s Address

Part 5 – Income You Earn or Pay For Child Support

If anyone in your household has income from a job or self-employment:

• Fill in this section to show all income anyone gets from tips, payments for service, and wages for all jobs, even if someone

has more than one job, and

• Send copies of papers that show all gross income received by anyone last month, such as paystubs. Gross income is

income received before

taxes are withheld. If anyone was employed in the last six (6) months, but did not receive income

from that job last month, we may need proof of final wages earned and last date worked from that employer.

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

Name Employer How Often Paid? Gross Pay

Still Employed?

Did anyone in the household get income from self-employment last month? Yes No

If yes, send a copy of the most recent Federal Income Tax Form 1040 for each selfemployed person along with your

application.

MO 886-4576 (8-18) Page 3 of 5

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)

Natural Gas Tank Propane tElec ric Wood Cylinder Propane Fuel Oil Kerosene

Are you currently without a secondary (other) heat source, because it got disconnected or you’re out of fuel? Yes No

Are you currently in threat of not having a secondary (other) heat source, because it may be disconnected soon or you’re low on

fuel? Yes No

If you answered yes to either question, please fill in the disconnection date or how much wood, propane, or pre-paid

electric you have:

List your secondary supplier’s name City

Whose name appears on the account? Account Number

Part 6 – Income That Isn’t Earned

If anyone in your household receives income that does not come from a job or self-employment:

• Fill in this section, and

• Send copies of papers that show all unearned income anyone received last month.

AMOUNT HOW OFTEN

SOURCES OF INCOME WHO RECEIVES THIS INCOME?

RECEIVED RECEIVED?

Social Security

Supplemental Security Income (SSI)

Temporary Assistance for Needy

Families (TANF)

Supplemental Aid to the Blind (SAB)

Blind Pension (BP)

Supplemental State Payments (SSP)

Foster Care

Alimony

Child Support

List 8-Digit Case Number: _

_________

Unemployment Compensation

Veterans Benefits

Pensions

Railroad Retirement

Rent Received from Land or Buildings

Money Received from Friends, Family,

or Organizations

Armed Forces Allotment

Union Funds or Strike Benefits

Worker’s Compensation or Temporary

Private Disability

Other Unearned Income

Specify: ________________________

MO 886-4576 (8-18) Page 4 of 5

Court-ordered Child Support that is paid to someone outside your household can be deducted so that it doesn’t count as

income. To receive this deduction, fill in your 8-digit Child Support case number below.

Did anyone pay court-ordered Child Support last month to someone outside of your household? Yes No

If yes, how much? Name of person who pays the Child Support

List the 8-digit Child Support Case Number

Part 8 – Notice That You Can Get a Fair Hearing – For informational purposes only

As an applicant for the Low Income Home Energy Assistance Program (LIHEAP), you may request a hearing for the

following reasons:

1) If your LIHEAP application is denied.

2) If your LIHEAP application is not reviewed timely.

A request for a hearing can be made in writing, by phone, by fax, or in-person.

Papers you must send with your application to avoid processing delays (send copies, not originals):

Application that is completely filled in, signed, and dated.

Proof of Social Security Number for everyone in the household. (Such as social security card, award letter, W-2)

Copies of utility and/or fuel bills for your primary (main) and secondary (other) fuel sources, including any

disconnection notices. The person listed on the fuel bill must be a member of the household who is age 18 or older.

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

Proof of all income (both earned and unearned) from last month for all household members who got it. Household

members who are active food stamp recipients do not need to provide proof of these incomes.

Copies of the most recent Federal Income Tax Form 1040 for any household members who earned money from self-

employment last month.

Part 9 – Your Consent for the LIHEAP Agency to Process (Review) This Application

Read the Consent for Processing in the box below and sign in blue or black ink. If you do not sign and date the application

in ink, your LIHEAP application will not be processed.

I hereby apply for assistance under the LIHEAP laws of the State of Missouri administered by the Department of Social

Services (DSS). I declare that the information I have given is true, correct, and complete to the best of my knowledge. I

realize that the information which Ihave given on this application will need to be verified by the LIHEAP agency.

If any household member declared on my application is currently receiving Food Stamps, TANF, or Child Support, I hereby

authorize the LIHEAP agency to use my Family Support Division (FSD) file to see if we qualify for LIHEAP. I hereby authorize

the LIHEAP agency and FSD to release information relating to my application for LIHEAP to my fuel supplier to determine if

I am eligible. I give permission to DSS to use information provided on this form for purposes of research, evaluation, and

analysis of the program.

I understand that I may be fined, imprisoned, or both under state or federal law if I make false statements on this

application in order to get benefits I am not entitled to receive.

Signature (Must sign in blue or black ink) Date

MO 886-4576 (8-18) Page 5 of 5

Part 7 – Savings and Other Accounts

If anyone in your household has savings or other accounts, fill in the total amounts of money everyone has in each type of

account.

Type How Much? Type How Much?

Checking: Single and/or Joint Accounts

Stocks/Bonds and Mutual Funds

Savings: Single and/or Joint Accounts

IRA/KEOGH and/or Deferred Compensation

Plans

CDs, Annuities, and/or Money Markets

WHERE TO MAIL 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 103

Columbia, MO 65203-4300

Phone number: (573) 443-1100

St. Louis County

Community Action Agency of St. Louis County (CAASTLC)

2709 Woodson Rd

Overland, MO 63114-4817

Phone number: (314) 446-4420

Andrew, Buchanan, Clinton, DeKalb

Community Action Partnership of Greater St. Joseph

(CAPSTJOE)

817 Monterey

St. Joseph, MO 64503-3611

Phone number: (816) 233-8281

Atchison, Gentry, Holt, Nodaway, Worth

Community Services, Inc. of Northwest Missouri (CSI)

PO Box 328

Maryville, MO 64468-0328

Phone number: (660) 582-3113

Barton, Jasper, Newton, McDonald

Economic Security Corporation of Southwest Area (ESC)

PO Box 207

Joplin, MO 64802-0207

Phone number: (417) 781-0352

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

Francois, Ste. Genevieve, Washington

East Missouri Action Agency (EMAA)

PO Box 308

Park Hills, MO 63601-0308

Phone number: (800) 392-8663

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

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

City of St. Louis, Wellston

Urban League (ULSTL)

3701 Grandel Square

St. Louis, MO 63108-3627

Phone number: (314) 615-3632

Jefferson, Franklin

Jefferson-Franklin Community Action Corporation (JFCAC)

PO Box 920

Hillsboro, MO 63050-0920

Phone number: (636) 789-2686

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

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

Missouri Valley Community Action Agency (MVCAA)

1415 S Odell Ave

Marshall, MO 65340-3144

Phone number: (660) 886-7476

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

Adair, Clark, Knox, Schuyler, Scotland

Community Action Partnership North East Missouri

(CAPNEMO)

PO Box 966

Kirksville, MO 63501-0966

Phone number: (660) 665-9855

Douglas, Howell, Oregon, Ozark, Texas, Wright

Ozark Action, Inc. (OAI)

710 E Main St

West Plains, MO 65775-3307

Phone number: (417) 256-6147

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

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

Jackson, Clay, Platte

Family Support Division - LIHEAP

P.O. Box 1005

Jefferson City, MO 65102-1005

Phone number: (855) 373-4636

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

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