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BREVARD COUNTY LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (Brevard County Board of Commissioners)

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FOR OFFICE USE ONLY DATE STAMP
□ Home Energy
□ Summer Crisis
□ Winter Crisis
□ Weather Related
□ Restored Electric/Gas after disconnection
□ Coronavirus (COVID-19) Assistance REVISED JUNE 2020
BREVARD COUNTY LOW INCOME HOME ENERGY
ASSISTANCE PROGRAM (LIHEAP) APPLICATION
1. Give the following information for the applicant first, then for each person living in your home. If more
than seven people are living in your home, list the additional people on a separate piece of paper,
giving the same information and attach it to this form. (Please print neatly and do not fax
application.)
Name
(First, Middle, Last)
Applicant
Number
Date of
Birth
Sex
Race
Relationship
to Applicant
Source of
Income**
Monthly
Income
**Source of Income: wages, self-employment, social security, child support, regular gifts, unemployment
compensation, retirement benefits, SSI, TANF/WAGES, pensions, and interest on savings, etc.
2. If your annual household income is less than 50% of the poverty guidelines, explain how you pay for
food, shelter, clothing, transportation, and home utilities.
3. Are you: Renting (apartment or home) OR own/purchasing your home?
4. How many disabled persons live in the household?
5. If you share your living or mailing address with others who are not part of your household, list their
names:
__________________; __________________; __________________; __________________;
6. If you, or anyone in your home, are not a U.S. citizen or an alien lawfully admitted for permanent
residence, give the person’s name and alien status under the Immigration and Naturalization Act.
Name: Alien Status:
Name: Alien Status:
7. Are you, or any member of your household, a member of the Porch Creek Indian Tribe?
☐ YES ☐ NO
Page 2 of 3
8. Does anyone in your household have any Health Insurance? ☐ YES ☐ NO
(If Yes, please check which one) ☐ Private ☐ Medicaid ☐ Medicare ☐ Healthy Kids
☐ Stay Well ☐ Kid Care ☐ Other
9. The address where you are living:
___________________________ ________________, Florida __________ __________
Address City Zip County
10. Your mailing address, if different from above:
___________________________ ________________, Florida __________ __________
Address City Zip County
11. Day time telephone number where you can be reached:
12. Check the programs that anyone in your household is currently eligible for or receiving assistance from:
☐ Community Services Block Grant
☐ Weatherization
☐ SNAP
13. If you, or any member of your household, have received Low Income Home Energy Assistance Program
(LIHEAP) or Emergency Home Energy Assistance for the Elderly Program (EHEAP) in the last 13 months,
complete the information below: FOR OFFICE USE ONLY
_________________________ ______________________________ ________________
Name of Agency Type of help Date
_________________________ ______________________________ ________________
Name of Agency Type of help Date
Verified by Staff:
14. Do any of the following situations currently apply to you? (Check the appropriate box below.)
☐ My electric/gas has been disconnected. ☐ I have little or no propane, fuel oil or wood for heat.
☐ My current electric bill is delinquent. ☐ I have a shut-off notice from my gas company.
☐ My current natural gas bill is delinquent. ☐ I have a shut-off notice from my electric company.
☐ None of the above currently apply to my
household.
☐ Other energy crisis – please describe
15. If your cost of home energy is included in your rent, give the name and telephone number of your
landlord. Attach a copy of a letter from the landlord confirming that your rent includes utilities.
Landlord: Landlord Telephone No.:
Page 3 of 3
16. If you live in a government subsidized housing complex, Section 8 housing, dormitory, nursing home,
adult foster home, or any kind of group living facility, complete the following:
Name of the place where you live:
___________________________ ________________, Florida __________ __________
Address City Zip County
17. Provide the following information about the primary source of energy you use to heat your home.
Give only one company.
Energy Source
Company’s Name
Customer’s Name
on the Account
Customer’s
Account Number
Company’s
Telephone #
Electric
Natural Gas
Propane
Fuel Oil
Wood
Other – Specify:
18. Provide the following information about the primary source of energy you use to cool your home.
Energy Source
Company’s Name
Customer’s Name
on the Account
Customer’s
Account Number
Company’s
Telephone #
Air Conditioning
Fans
19. If not given above in questions 17 or 18, please provide the following information about your electric
company.
Company’s Name
Customer’s Name on
the Account
Customer’s Account
Number
Company’s Telephone #
20. Attach a copy of your current bills for all companies listed above in questions 17, 18, and 19.
FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I
understand that priority in providing assistance will be given to those households with the lowest income and
greatest need; i.e. those households in which the elderly, disabled, medically needy or where children reside.
I authorize the agency to make benefit payments directly to my energy supplier. I am aware that after I have
provided all the information requested, if I am applying for Crisis Assistance, the Agency has 18 hours to
approve or deny my application; and, if I am applying for Home Energy Assistance, the Agency has 15 days to
approve or deny my application. I am also aware that if I am not approved or denied within the time allowed,
or not approved for the correct amount, I have a right to an appeals hearing.
_________________________ ________ _________________________ _________
APPLICANT’S SIGNATURE DATE ELIGIBILITY SPECIALIST DATE
_________________________ _________
SUPERVISOR/EDIT STAFF DATE
Phone (321) 633-1951 ● Fax (321) 633-1958
Website: BrevardCounty.us
Housing and Human Services
Community Action Agency
400 S. Varr Avenue
Cocoa, Florida 32922
NOTICE REGARDING COLLECTION OF SOCIAL SECURITY NUMBERS
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM
The following disclosure is being made pursuant to Section 119.071(5), Florida Statutes.
Social Security numbers of applicants and household members are requested because this information has been
determined to be imperative for the performance of the duties and responsibilities prescribed by law under the
Low Income Home Energy Assistance Program. This information is not required by state or federal law; however,
Social Security numbers are necessary to determine eligibility for program services and specifically for the following
purposes:
1. To verify an applicant’s identity.
2. To verify household size.
3. To verify household income.
A Social Security number collected pursuant to this notice can only be used by the Florida Department of Economic
Opportunity and the Brevard County Housing and Human Services/Community Action Agency for the purposes
specified above.
Nondisclosure except under limited circumstances. Social Security numbers will not be disclosed to others unless
required or authorized by Florida Law. Section 119.071(5), Florida Statutes, allows disclosure of a person’s Social
Security number under the following specific, limited circumstances:
• If disclosure is expressly required by federal or Florida Law or is necessary for the agency o
r
g
overnmental entity to perform its duties and responsibilities;
• If the individual expressly consents to disclosure in writing;
• If disclosure is made to prevent and combat terrorism pursuant to the U.S. Patriot Act of 2001 or
Presidential Executive Order 13224 (blocking property and prohibiting business transactions with
persons who commit, threaten to commit, or support terrorism);
• For an agency employee and dependents, if disclosure is necessary to administer the person’s
health benefits or pension plan funds; or
• If disclosure is for the purpose of the administration of the Uniform Commercial Code by the office
of the Secretary of State.
• If disclosure is requested by a commercial entity for permissible uses under the federal Driver’s
Privacy Protection Act of 1994, the federal Fair Credit Reporting Act, or the federal Financ
ial
Services Modernization Act of 1999 (for example, to verify the accuracy of personal information
provided by the individual to the commercial entity; use by an insurer in connection with claims
investigation or anti-fraud activities; for use in connection with a credit transaction.)
Acknowledgment of Receipt of Notice
I confirm that I have been provided a copy of this notice regarding the collection of my Social Security number and
the Social Security numbers of all household occupants as part of the application process for the Low Income Home
Energy Assistance Program.
__________________________________________ ______________________________
Applicant’s Signature Date
Phone (321) 633-1951 ● Fax (321) 633-1958
Website: BrevardCounty.us
Housing and Human Services
Community Action Agency
400 S. Varr Avenue
Cocoa, Florida 32922
BREVARD INFORMATION COLLABORATIVE (B.I.C.) PROJECT CLIENT RELEASE
(This form must be completed by every Adult Household Member)
I understand and acknowledge that this agency is a member of the Brevard Information Collaborative
Project (hereafter referred to as B.I.C.), and I consent to and authorize the collection of data and information
maintained by this agency to B.I.C. and affiliated agencies, provided such agency is a party to the B.I.C. agency
agreement under which the agency has specifically agreed to share information. These agencies include, but
are not necessarily limited to participants in the Homeless Management Information Systems (HMIS) grant,
and the United Way Outcome Measures Pilot Project. The data, information and records gathered and
prepared by the Agency and B.I.C. will be included in the database and may be utilized by B.I.C. and affiliated
agencies to: a) provide individual case management; b) produce reports regarding utilization of services; c)
track individual program outcomes; d) provide accountability for individuals and entities that provide funds for
use in providing services in Brevard County; e) identify unfilled service needs and plan for the provision of new
services; f) allocate resources among agencies engaged in the provision of services in Brevard County and g) be
used for all other uses to be deemed appropriate by B.I.C. I understand and acknowledge that my data and
information may be used in aggregate data along with information off other individuals served by the Agency
for the purposes described above, I understand and acknowledge that data, information and records
pertaining to the services provided to me by the Agency will only be disclosed to agencies, individuals and
entities other than B.I.C. only with my written authorization.
I understand and acknowledge that the data pertaining to the services provided to me may include
medical/health information and other information, the privacy of which may be protected by Federal or
Florida State Laws and expressly consent to the release of such information in accordance with these
protections.
I understand and acknowledge that I have the right a) to inspect, copy, and request amendment of all
records maintained by the Agency related to the provision of services and to receive a paper copy of this form;
and b) to file a grievance if I believe my privacy rights have been violated. This grievance must be submitted to
the Brevard County Community Action Agency Supervisor at 400 South Varr Avenue, Cocoa, Florida 32922 and
such grievance will be responded to in accordance with the B.I.C. Policies and Procedures manual.
I understand and acknowledge that I have the right to opt out of having my data information and
records disclosed to B.I.C. and affiliated agencies by providing notice to the Agency and that I am entitled to
services regardless of my decision. I further understand and acknowledge that I may revoke this consent at
any time by providing written notice to the Agency.
Client Name: _______________________________________
Agency Name: _______________________________________
Client Signature: _______________________________________ Date: ___________________
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BREVARD COUNTY LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (Brevard County Board of Commissioners)

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Completed 17 July 2020

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