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Department of Public Health and Human Services STATE (State of Montana)

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Heallhy
People.
Healthy
Communities..
Department of Public Health and Human Services
STATE OF MONTANA
Low Income Energy Assistance Program (LIEAP), Low Income
Home Water Assistance Program (LIHWAP) and Weatherization Application
To apply for the LIEAP and LIHWAP, this application must be completed and returned to your local
eligibility office LIEAP heat assistance applications will NOT be accepted after April 30, 2022.
However, you can apply for LIHWAP or Weatherization all year. LIEAP, LIHWAP and Weatherization
benefits are only for the dwelling you live in at the time of application. If you move any time after
applying, please contact your LIEAP/LIHWAP/Weatherization office.
Complete each section of the LIEAP/LIHWAP/Weatherization application. You must also provide
verification of all identities,
incomes, resources, heat, electric
and/or water bills. (see table at right).
A LIEAP/LIHWAP/Weatherization
application cannot be processed
without this verification.
LIEAP/LIHWAP/Weatherization
eligibility will be determined based
upon the circumstances at the
time of application.
If you or a household member is
over the age of 60, or a person
with a disability, call 1-800-551-
3191 for help filling out this
application.
Note: All adult household members
who live on a reservation (other
than the Crow Reservation), and
who are Native American, enrolled tribal members or direct descendants should contact their
Tribal office for assistance. Native American household members who live on the Crow
reservation should contact District VII Human Resource Development Council (Billings) for
assistance.
Application submitted
in month of:
Provide income verification for the
months of:
August 2021 May 2021 through July 2021
September 2021 June 2021 through August 2021
October 2021 July 2021 through September 2021
November 2021 August 2021 through October 2021
December 2021 September 2021 through November 2021
January 2022 October 2021 through December 2021
February 2022 November 2021 through January 2022
March 2022 December 2021 through February 2022
April 2022 January 2022 through March 2022
May 2022 February 2022 through April 2022
June 2022 March 2022 through May 2022
July 2022 April 2022 through June 2022
Failure to provide all requested information and verifications will delay the eligibility
determination and may result in application denial.
Send completed application and all required documentation to your local eligibility office.
The last page of this application lists the addresses for each local office.
APPLICANT RIGHTS
• To inquire and be informed about benefits, conditions of eligibility, scope of the program and related services available, and regular and
emergency benefits.
• To be determined eligible or ineligible based upon the information and corresponding documentation provided with the completed application.
• To receive timely written notice of denial, reduction, or termination of assistance.
• To be informed of the Fair Hearing process.
• To have a confidential relationship.
• To have your Civil Rights protected. This is an equal opportunity program. Discrimination is prohibited.
Fair Hearing Rights:
If the completed application has not been acted on in a timely manner or if you disagree with any adverse action taken on your case you may
request a fair hearing. A fair hearing request may be filed with your local Eligibility Office or the Office of Administrative Hearings. The Office of
Administrative Hearings address is:
Office of Administrative Hearings - Box 202922 - Helena, Montana 59620-2922
Use the codes below to complete Section 1 - Households Members section on the next page.
Relationship:
SP/SO - Spouse/Significant Other
CH - Child
GC - Grandchild
FC - Foster Child
PA - Parent
SB - Sister/Brother
AU - Aunt/Uncle
NN - Niece/Nephew
CO - Cousin
EX - Ex-Spouse
NR - Not Related
OR - Other-Related
Hispanic Status, US Citizen, Tribal
Member, Disabled:
Yes or No
Race Status:
(Multiple Selections Allowed)
1 - White
2 - Black/African American
3 - American Indian/Alaska Native
4 - Asian
5 - Native Hawaiian/Pacific Islander
Highest Grade Completed:
0 – 11 - Grades
GED - GED-Completed
HS - High School Diploma
12+ - Grade 12 + some Post-Secondary
AS – 2 Year College Graduate
VT – Vo-Tech Graduate
BA – 4 year College Graduate
MS – Graduate other post-secondary schl
FT - Full-Time
PT- Part-Time
SW – Seasonal Worker
US – Unemployed, short-term,
6 months or less
UL – Unemployed (Long-Term,
more than 6 months)
NE - Not Employed (Not in
Labor Force)
R - Retired/Not Working
NA – Not Applicable
Military Status
V – Veteran
AM – Active Military
NA – Not Applicable
Health Insurance Status:
MA - Medicaid
MC - Medicare
PV – Private (Direct Purchase)
CH - Healthy Montana Kids
HA – State Health Ins for Adults
VA - Veterans Administration
EB – Employment Based
OT - Other
NN - None / Unknown
SNAP: Yes or No
NOTE: Entries for gender,
Hispanic, and race are not
required.
Page 2
Provide all requested information for all persons living in the house regardless of relationship whether or not you consider them a household member.
DPHHS-EAP-088
(Rev 07/2021)
01
SELF
MM/DD/YY
02
03
04
05
06
07
08
List everyone who lives in the home. Attach another sheet for additional household member information if needed.
How many people live in
this residence? ____
List everyone below
Last Name, First Name, MI
Alias or
Maiden
Name
(Other
Names
Used)
Relationship
to Head of
Household
Social Security
Number (SSN)
Birth Date
Age
Gender
Hispanic
Race
U.S. citizen
Tribal Member
Military Status
Disabled
Health Insurance
Highest grade
Completed
Work status
Registered
Alien
SNAP
Page 3
Section 1 HOUSEHOLD MEMBERS
__________________________________________________________________________________________________________________________
DPHHS-EAP-088
(Rev 07/2021)
COLLEGE STATUS (provide copies of all financial aid award letters)
Has any member of the household been enrolled at least half-time in a college or university in the last three (3) months? Yes No
If yes, which household members? ________________ _______________________ ______________________ ___________________
If yes, include a copy of all financial aid received. Which quarters or semesters did they attend? ___________________________________
If yes, was that person claimed last year as a dependent for Federal income tax purposes by someone in another household? Yes No
TRIBAL STATUS (see page 1 regarding Native American applicants)
List each Tribal Member/Direct Descendant’s tribal affiliation(s): ____________ ____________ ____________ ____________ ______________
Note: All adult household members who live on a reservation (other than the Crow Reservation), and who are Native American, enrolled tribal
members or direct descendants should contact their Tribal office for assistance. Native American household members who live on the Crow
Reservation should contact District VII Human Resource Development Council (Billings) for assistance.
VETERAN STATUS
Do any Veteran household members receive VA compensation? Yes No If yes, provide a copy of VA award letter.
WEATHERIZATION
Do any household members have health conditions to take into consideration for weatherization of the residence? Yes No
If yes, which household members? ______________ ____________ ____________ ___________ ____________ ______________
If yes, list conditions. If you need additional space, include a separate piece of paper. ____________________________________________________
WATER ASSISTANCE
Do you need help paying your water bill (excluding water well expenses)? Yes No
CHILD STATUS (Provide Child Support case #s and verification)
Does each child listed on the application live in this home more than 50% of the time? Yes No
Is there an active Child Support order for any of the children listed on the application? Yes No If yes, from what state ? _______________
Has a household member received support (even if not ordered) in the past three (3) months for any child listed on the application? Yes No
For any yes answers, specify which child(ren) __________________________ __________________________ _______________________
If all members of your household receive SNAP benefits, you may be exempt from providing some of the
documentation requested. Contact your local office for more information.
Page 4
DPHHS-EAP-088
(Rev 07/2021)
Section 2 HOUSEHOLD ADDRESS INFORMATION
This application is for where you are currently living at the time of application. If you move before approval, you must reapply.
Physical Address: (heat/electricity/water service address): ______________________________ City______________ County ___________ Zip ______
Mailing Address or PO Box: (if different from residence): ____________________________ City_______________ County ____________ Zip ______
What date did you move to this address? _______________ If after 10/1/2021, did you move here from out of state? Yes No
Were you responsible for heating costs at your prior location? Yes No
Is this property located within the boundaries of a Native American reservation? Yes No
Home Phone: _________________Message Phone: ___________________Cell Phone: ___________________ Other Phone (Specify):___________
Email Address (Optional): _______________________________________
Housing type: (check one)
Mobile Home
Double-Wide Mobile Home
House – Modular (Single Family)
Apartment or Duplex, etc. *
Total # of units in building: ___________)
NonTraditional Housing (Cabin, Camper, RV, etc.)
Number of bedrooms:
(check one)
One Four
Two Five
Three Six
Rent or Own Home:
Own Home
Rent Home
Year Home was built?
__________________
Rent Mobile
Lot:
Yes
No
If you live in a Non-Traditional Housing, Camper or RV, are you plugged into a permanent electrical source? ☐ Yes ☐ No
If you rent, provide name, address, and telephone number of your landlord:
_________________________________________________________ (______)______________________________________________
Landlord Name Phone Number
_________________________________________________________ _____________________________________________________
Address City/State/Zip
Does your rent include electricity, heat, water costs? Do you receive governmental rent assistance? Yes No
Page 5
Section 3 HOUSING TYPE INFORMATION
DPHHS-EAP-088
(Rev 07/2021)
Heat Service You Use the Most (Mark One)
Other Heat Service (Mark all that apply)
Natural Gas
Natural Gas
Electric _________________________
Electric _________________________ _________________________
Propane Main Vendor
Propane Additional Vendor Additional Vendor
Fuel Oil
Fuel Oil
Wood _________________________
Wood _________________________ _________________________
Coal Account Number
Coal Account Number Account Number
Past due amount owed:____________
Past due amount owed:____________
Electricity Provider _________________________ _________________________ None Off-Grid
(If not identified above) Electric Provider Account Number
Water Provider _________________________ Water past due amount: ____________________________ None (Well)
If your heat, electric or water bill is not in a household member’s name, whose name is on the bill? ___________________________________________
In the past year has your household applied for or received assistance with heat, electric or water costs from another agency? Yes No
If yes, please specify where, when and provide verification of the assistance amount: ______________________________________________________
A copy of your most recent HEAT, ELECTRIC and WATER bill(S) showing NAME, current ADDRESS and ACCOUNT NUMBER(S) must be attached. If your
main heat source is oil or propane and you do not have a bill; obtain a letter of service from your supplier. If your main heat is wood or if your main heat
is included in your rental payment or is not in your name; contact your local office as you may need an additional form.
Do you have Central Air Conditioning? Yes No
Do you have Window/Wall Air Conditioning (including evaporative cooler) Yes No
Has your household received a utility (heat) past due notice in the last 30 days? Yes No
Do you have less than 10% Deliverable Fuel (oil/propane/coal/wood) on hand? Yes No
Is your utility (heat) service currently disconnected? Yes No
Are you completely out of Deliverable Fuel (oil/propane/coal/wood)? Yes No
Has your household received a water past due notice in the last 30 days? Yes No
Is your water service currently disconnected? Yes No
If your furnace or main heat is not working properly, describe: ________________________________________________________________________
(Other help or assistance may be available)
Page 6
Section 4 HOME HEAT AND WATER INFORMATION
DPHHS-EAP-088
(Rev 07/2021)
Please check ALL the following sources of income that have been received by ALL MEMBERS of your household within the past three (3) months.
TANF (includes Tribal) Self Employment Alimony Payments
SNAP / Food Stamp Wages / Tips (Salary) Worker’s Comp
Supplemental Security Income Unemployment Educational Grants
Veteran Administration Interest Income Loans
General Assistance (includes Tribal) Odd jobs Gifts (Money)
Social Security Property Income Pension/Retirement Income
Financial Aid Non-Cash Income Utility Payment (Section 8 Housing)
Child Support: If paid through MT CSED, provide case #’s ____________________________________________
Other: If checked, please explain in the following space: _____________________________________________
If anyone in your
household pays premiums
for health, dental, or
optical insurance, provide
verification of those
payments for the prior
three (3) months for a
possible reduction to your
countable income.
Section 6 INCOME OF HOUSEHOLD MEMBERS
Enter the requested information for all household members regardless of age or relationship. Begin with last month and go back three (3) months.
Month
Sources and Amounts of Gross Income (Specify each source and who received it.)
Total Gross Income
for Month
EXAMPLE: October
EXAMPLE: Joe-ABC Company $650; Jane-SS $500; Jane-Child Support-$250
$1,400
1
2
3
If there is zero (0) income, please explain your means of survival.
Page 7
Section 5 SOURCES OF INCOME
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
DPHHS-EAP-088
(Rev 07/2021)
Section 7 RESOURCES AND BUSINESS EQUITY
COPIES OF DOCUMENTATION TO VERIFY ALL GROSS INCOME MUST BE INCLUDED
Please answer all questions for each of the resources listed below for all household members regardless of relationship. If the resource listed does not
apply to your household, please print “None” under each section headed “FINANCIAL INSTITUTION”.
RESOURCE
You must provide full bank statements or other verification of all resources
FINANCIAL INSTITUTION
CURRENT VALUE
1. Cash on Hand: $_______________ Checking Account(s): $______________
Savings Account(s): $_________________
$
2. Certificates of Deposit – Individual Retirement Accounts -
Tax Sheltered Annuities - 401(K); 403(B) or any other retirement account
$
3. Cash value of stocks, bonds and other investments
$
4. Value of business assets, rental properties or property leases.
(Self-employed households must provide this information).
$
5. Physical address(es) and County of property/real estate other than the home
in which you live and its adjoining land.
$
6. If you sold any real estate property within the past 12 months, provide closing settlement papers and specify if it was your primary residence.
COMMENTS: If you wish to make any comments regarding any special situation, or you wish to clarify any of your responses, please do so in the space
provided below. If you need additional space, please use a separate piece of paper.
Page 8
DPHHS-EAP-088
(Rev 07/2021)
Section 8 AUTHORIZATION
READ THE FOLLOWING. SIGN AND DATE WHERE INDICATED.
I understand that this application is for Federal funds and that any falsification or concealment of a material fact may be prosecuted under Federal or State Laws. I understand
the application must include information for all individuals living in the household including all gross income and resources. False, misleading, or incomplete information may
result in the denial or termination of assistance, and/or potential repayment of assistance funds provided. If you are receiving another form of federal assistance and it is
determined that there was a duplication in subsidy, you will be required to return the funds that were overpaid to Montana Department of Public Health and Human Services.
I understand that Heat Assistance benefits are computed for October 1 through April 30. I am responsible for any other costs not covered by any benefits I may have received. I
certify that the information provided herein is true, complete, and correct to the best of my knowledge. I authorize the Department to communicate and share information to
all third-party payees listed in the application and persons or organizations assisting in the application process, including but not limited to, late fees, security deposit, utility or
utility deposit information. I have read; or have had read to me; all the above and all questions have been answered to my satisfaction.
RELEASE OF CONFIDENTIAL INFORMATION (AUTHORIZATION TO MONTANA DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES TO OBTAIN PERSONAL INFORMATION)
I authorize any individual, company, agency, or other entity which has information about me or my household, including, but not limited to, the information sources listed below
to release or disclose information to the Montana Department of Public Health and Human Services (DPHHS) and/or to any agent or contractor of the DPHHS which is authorized
to determine eligibility for Heat or Water Assistance or Weatherization benefits. I authorize the disclosure or release of any information relevant to my eligibility for Heat or
Water Assistance or Weatherization benefits, including, but not limited to, the information to be released or disclosed listed below. I understand any information obtained will
be kept confidential and will be used only for the purposes directly connected with the administration of benefits or services and only during the pertinent time period. I further
understand that any information obtained may be released or disclosed to a proper government agency, court of law, or law enforcement agency for purposes of legal
investigative actions concerning fraud. I further understand that information contained on this application can be used in DPHHS electronic databases for the determination of
eligibility for programs and/or to record services provided to my household for federal and/or state reporting purposes.
INFORMATION SOURCE: Banks, Savings & Loans, Credit Unions, Employers, Social Security Administration, Veterans Administration, State Department of Labor and Industry,
Internal Revenue Service, State Department of Revenue, State Compensation Insurance Fund, Unemployment Compensation Division, County Clerk & Recorder, Bureau of Indian
Affairs, Utility Suppliers and Vendors, Other Social Services Providers, Landlord, Child Support Enforcement Division, Offices of Public Assistance, Montana Emergency Rental
Assistance, Low-Income Home Water Assistance Program, Energy Share, other assistance programs and other sources for which a household may be eligible and to reduce
potential for duplication of effort.
INFORMATION TO BE RELEASED OR DISCLOSED: Checking, Savings, Certificates of Deposit, Stocks & Bonds, Safety Deposit Boxes (to be opened only in the presence of the
client or his agent and representatives of the financial institution), Gross Earnings, Social Security Payments, V.A. Benefits, Personal and Business Income, Workers
Compensation, Unemployment Compensation, Family Composition, Size of Home, Per Capita Payments, Lease Payments, Indian Income Maintenance (IIM) Accounts, Amount of
Heat Assistance received from agencies, Utility Account Information: including, but not limited to, Utility Account and Billing Information, Child Support Payments, Benefit
Information.
X_________________________________________________________ Date:__________________ SSN: ____________________
Signature of head of household. If signing on a person’s behalf provide a copy of the Power of Attorney or authorization.
X_________________________________________________________ Date:__________________ SSN: ________________________
X_________________________________________________________ Date:__________________ SSN: ________________________
X_________________________________________________________ Date:__________________ SSN: ________________________
Signatures of all other household members age 16 or older.
Page 9
DPHHS-EAP-088
(Rev 07/2021)
APPLICANT CHECKLIST
Make sure you have done the following things:
Completed all spaces on the application, especially Income in Section 5 and each Resource line in Section 7.
Completed physical and mailing address information.
Ensured that all people who reside in the dwelling are included on the application.
Ensured that all household members age 16 or older have signed Section 8.
Included a copy of your most recent heat, electric and/or water bill(s) for the assistance for which you are applying.
Included verification of all gross incomes received in the past three (3) months, from all sources, for all members of the household
regardless of the age or relationship.
Included full bank statements for all open bank accounts and verification of other resources including Reliacard, Direct Express, and
employer payroll cards for all household members.
Included photo identification for all household members 18 or older and photo identification or birth certificates for all household
members younger than 18.
Included Social Security Numbers (SSNs); or if any household member does not have a SSN; included proof of citizenship or lawful entry
into the US with the intent of establishing permanent residency; for all household members.
Checked the address list on the last page for mailing your completed application to the correct eligibility office.
If anyone in your household pays premiums for health, dental, or optical insurance, provide verification of those payments for the prior
three (3) months for a possible reduction to your countable income.
The Low Income Home Water Assistance Program (LIHWAP) is a temporary program that will terminate September 30, 2023.
Applicant must receive water from a Public Water System (PWS) as defined by ARM 17.38.202(5).
Wells and infrastructure are specifically excluded per federal guidance.
Water bill must be in the applicant’s name.
Payments for past due amounts from prior to March 2021 are ineligible for payment.
NOTE: You should receive a letter within 45 days telling you whether you are eligible after we receive your completed
application. Your application cannot be processed without all the information requested.
Page 10
DPHHS-EAP-088
(Rev 07/2021)
Local Eligibility Offices
Find your county and return the application to the office listed.
If you live in this county:
Return application to:
Carter
Prairie
Custer
Richland
Daniels
Roosevelt
Dawson
Rosebud
Fallon
Sheridan
Garfield
Treasure
McCone
Valley
Phillips
Wibaux
Powder River
Action for Eastern Montana
2030 North Merrill
P.O. Box 1309
Glendive, MT 59330-1309
Ph. 377-3564 or 1-800-227-0703
Blaine
Hill
Liberty
District IV HRDC
2229 5
th
Avenue
Havre, MT 59501
Ph. 265-6743 or 1-800-640-6743
Cascade
Chouteau
Glacier
Opportunities Inc.
905 First Ave North
P.O. Box 2289
Great Falls, MT 59403-2289
Ph. 761-0310 or 1-800-326-0955
Big Horn
Carbon
Stillwater
Sweet Grass
Yellowstone
District VII HRDC
3116 First Ave North
P.O. Box 2016
Billings, MT 59103
Ph. 247-4778 or 1-800-433-1411
Missoula
Mineral
Ravalli
District XI Human Resource Council
1801 South Higgins
Missoula, MT 59801
Ph. 728-3710
Flathead
Lake
Lincoln
Sanders
Community Action Partnership of NW MT
214 Main Street
P.O. Box 8300
Kalispell, MT 59904-1300
Ph. 758-5433 or 1-800-344-5979
If you live in this county:
Return application to:
Fergus
Golden Valley
Judith Basin
Musselshell
Petroleum
Wheatland
District VI HRDC
Centennial Plaza
300 First Avenue North, Room 203
Lewistown, MT 59457
Ph. 535-7488 or 1-800-766-3018
Gallatin
Meagher
Park
District IX HRDC
32 South Tracy Avenue
Bozeman, MT 59715
Ph. 587-4486 or 1-800-332-2796
Broadwater
Jefferson
Lewis & Clark
Rocky Mountain Development Council
LIEAP Office
648 N. Jackson
P.O. Box 1717
Helena, MT 59626-1717
Ph. 447-1625 or 1-800-356-6544
Beaverhead
Deer Lodge
Granite
Madison
Powell
Silver Bow
Action Inc. – Human Resource Council
25 W Silver Street, Butte, MT 59701
P.O. Box 39, Butte, MT 59703
Ph. 533-6855 or 1-800-382-1325
Pondera
Teton
Toole
North Central Area Agency on Aging
311 S Virginia St, Suite 2
Conrad, MT 59425
Ph. 271-7553 or 1-800-551-3191
For additional information visit: lieap.mt.gov
Page 11
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