Fillable Form 2020: complete all sections and questions, sign (Hawaii)

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Form 2020: complete all sections and questions, sign (Hawaii)

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State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
1
L-1 (09/19)
2020
APPLICATION FOR LIHEAP
Please complete every section and answer each question. Sign the application and the Rights and Obligations form. Failure to
complete all sections and questions, sign the application and/or Rights and Obligations, or provide the requested documentation
noted on the application, will delay processing your application and may result in your application being denied.
PLEASE PRINT CLEARLY
APPLICANT/HOUSEHOLD INFORMATION
YOUR NAME: (Last, First, MI)
Phone number:
Alternate phone number:
RESIDENCE ADDRESS: (Where you live)
ZIP CODE
MAILING ADDRESS: (IF DIFFERENT FROM ABOVE)
ZIP CODE
Complete the following for every person living in your home, including yourself (attach additional page if necessary). The first name on the
application should be the applicant. Check if receiving SNAP, WELFARE, and SSI or if Disabled. Provide proof of age for all children 5 & under.
Provide proof of identity for all Adults.
Name
(Last, First, Middle)
(Jr., Sr., III)
Relationship
to you
Date of
birth
Age
Social Security
Number
SEX M/F
SNAP
WELFARE/
CASH
SSI
DISABLED
1
SELF
2
3
4
5
6
7
***Are there additional people in your home?
☐
YES
☐
NO IF “YES” list them on a separate sheet of paper***
WHAT IS THE PRIMARY LANGUAGE SPOKEN IN YOUR HOME? __________________________________________
DO YOU READ, WRITE AND UNDERSTAND ENGLISH? _________________________________________________
DO YOU NEED AN INTERPRETER? ☐ YES ☐ NO
If yes:
☐ I will provide my own interpreter.
☐ I would like an interpreter provided. LANGUAGE: ___________________________________
Do you have an Air Conditioner? ☐ Centralized ☐ Window/Split System How many do you have? __________
Do you use A/C daily? ☐ Yes ☐ No How many hours? _______
Do you have a Photovoltaic system(s)? ☐ Yes ☐ No
Were you provided information on energy savings? ☐ Yes ☐ No
Would you like information on energy savings? ☐ Yes ☐ No
Have you learned how to save on energy costs? ☐ Yes ☐ No
Were you referred to a non-energy service such as a food pantry, job search, or housing? ☐ Yes ☐ No
FOR OFFICIAL USE ONLY:
☐ Crisis ☐ Credit
Application Date: __________________
Agency: __________________________
Worker:__________________________
AP T . NO
APT. NO
CITY & STATE
CITY & STATE
State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
2
L-1 (09/19)
DWELLING INFORMATION
Do you receive housing assistance?
☐
Yes
☐
No
If yes, what type of assistance do you receive? (check all that apply)
☐ Section 8 ☐ Senior/Disabled Housing ☐ Public/County Housing ☐ HUD
☐ Other: ________________________________________
If you are in subsidized/public housing, do you receive a utility allowance check? ☐ Yes ☐ No
If yes, how much? $_______________
☐
Rent $___________ (you pay) + $ ____________ (Housing Assistance payment) = $_____________ (total rent)
☐ Mortgage $____________
☐ Maintenance Fee $ ____________
☐ I own my home and do not pay a mortgage.
☐ I do not pay any rent, it is paid by someone else.
Name of person who pays rent _________________________________ Relationship ________________________
Landlord’s name: ___________________________________________________________________________________
Landlord’s Address: __________________________________________________________________________________
Telephone number: ________________________________________
UTILITY INFORMATION
I WOULD LIKE TO APPLY FOR (Check only one):
☐
Energy Credit (EC)
☐
Energy Crisis Intervention (ECI)
I WOULD LIKE TO APPLY FOR UTILITY ASSISTANCE FOR (Check only one):
☐
ELECTRIC
☐
GAS
UTILITY SERVICE IS DISCONNECTED OR WILL BE DISCONNECTED:
☐
YES
☐
NO
DISCONNCTION DATE: ________________________________
ELECTRIC: (HECO, HELCO MECO, KIUC)
Subscriber’s name: ____________________________________
Residence Address: ____________________________________
Account Number: _____________________________________
GAS: (Hawaii Gas Company)
Subscriber’s name: _________________________________
Residence Address: _________________________________
Account Number: __________________________________
NON CITIZEN INFORMATION
COMPLETE THIS SECTION IF YOU ARE NOT A U.S. CITIZEN: Attach verification of immigration status.
NAME
BIRTHPLACE DATE OF ENTRY
INS Form or Alien
Registration Number
State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
3
L-1 (09/19)
INCOME INFORMATION
EARNED INCOME:
List all employed household members. Include employment from January to present day. All earnings must be verified.
Name
Employer Name & Address/
Job Title
Start date
MM/YY
End
date
MM/YY
Hours
per
week
Rate per
hour
Gross pay
per pay
check
Tips
per
month
Pay
frequency
SELF EMPLOYMENT INCOME:
Earning money from a business, baby-sitting, out of home sales, Swap Meets, garage sales, car repairs, etc.
List all employed household members. Include employment from January to present day. All income and expenses must be verified.
Self Employed Person
Type of Business
Hours per
week
Monthly Gross
Tips
Monthly Expenses
DOES ANYONE EXPECT A CHANGE IN INCOME (SUCH AS A NEW JOB, CHANGE IN WAGES, ETC.)?
☐
YES
☐
NO
NAME OF PERSON
EXPLAIN CHANGE
DATE OF CHANGE
UNEARNED INCOME:
All unearned income must be verified.
Income Type
Name
Amount
How Often Received?
(monthly, weekly)
Welfare/Cash Benefits
Social Security
Supplemental Security Income (SSI)
Unemployment Insurance
Temporary Disability Insurance
Veteran’s Benefits
Worker’s Compensation
Pension
Child Support
Alimony
Foster Care Payments
Imua Kakou (Voluntary Foster
Payments to young adults)
Insurance Settlements - monthly
Money from friends, relatives,
charities, contributions, gifts
Lump Sum (insurance settlements,
retroactive payments)
Other (Cash from employment,
paid under the table, collecting
cans)
State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
4
L-1 (09/19)
CERTIFICATION OF ELIGIBILITY, UNDERSTANDING & RELEASE FOR ALL HOUSEHOLD MEMBERS 18 YRS+
My signature on this application gives my permission to the Department of Human Services or its authorized agent to (a) check any information I
give about where I live, my jobs, income, energy supply and energy supplier/utility company; (b) share information with my energy supplier and
receive information from my energy supplier to allow DHS to obtain a record of my annual energy consumption, cost and billing information for the
purpose of program evaluation, operation, or reporting;
1. I affirm that Hawaii is my legal residence.
2. I understand that I have the right to discuss any action regarding your application with the Community Action Agency or the State.
3. I understand that I have the right to appeal any negative decision or undue delay in processing this application. An appeal must be
submitted in writing within 90 days from the date of notification. I have the right to examine prior to the hearing, my case file and any
documents used in the determination of the appealed action. I have the right to legal representation.
4. I understand any Social Security number(s) given will be used in the administration of this program, including cross matches with other
programs.
5. All records are kept confidential.
6. In accordance with Federal law and U.S. Department of Health and Human Services (HHS) policy, discriminating on the basis of race,
color, national origin, sex or disability is prohibited. To file a complaint of discrimination with DHS contact the Civil Rights Compliance
office at 1390 Miller St., Room 214, or call (808) 586-4955, or contact HHS, Director, Office for Civil Rights, Room 506-F, 200
Independence Avenue, S.W. Washington, D.C., 20201 or call (202) 614-0403(voice) or (202) 619-3257 (TDD), HHS is an equal opportunity
provider and employer.
7. I understand that if my household is eligible for a one-time payment of LIHEAP benefits, it must be sent directly to my utility company
and will be deposited into the utility account at the utility company for which I requested help. I also understand that I must have an
open active account with the Utility Company when the LIHEAP funds are posted, or I will not be eligible for LIHEAP.
8. The Agency or Community Action Program and the State of Hawaii Department of Human Services’ Low Income Home Energy Assistance
Program shall not be responsible for the delivery or non-receipt of mail.
9. Any or all unused funds may be returned to State.
10. I know that if I give false information, I can be penalized and/or prosecuted.
11. I understand that I may not qualify should LIHEAP run out of funds.
The Hawaiian Electric Companies and the State of Hawaii Department of Human Services’ Low Income Home Energy Assistance Program
(LIHEAP) reached an agreement which will automatically qualify LIHEAP approved households with a Residential Rate schedule (Schedule R)
for the Utility’s Tier Waiver Provision. If determined eligible you will receive a letter in the mail from the Utility Company with more detailed
information. For all Energy Credit eligible households, the provision will begin in January. For Energy Crisis Intervention households, the
provision will begin once determined eligible. The Tier Wavier Provision will be provided for 12 months.
Applicants misrepresenting their household’s circumstances will be disqualified from applying for LIHEAP for one federal fiscal
year or benefit year per infraction.
I certify that, subject to penalties provided by law, the information I give is true, correct and complete to the best of my
knowledge.
___________________________________________ _____________________________________________
Signature of Applicant Date Signature of Applicant Date
___________________________________________ _____________________________________________
Signature of Applicant Date Signature of Applicant Date
_____
________________________________________________
Witness if Signature is “X” Date
I helped the applicant fill out this form. I understand that anyone helping another person in dishonestly getting benefits is subject to criminal
penalties. I certify that the answers given by me on this form ☐ is what I know personally about him/her; or ☐ was provided by the applicant.
______
_____________________________________ ______________________________________________
Print Name Signature Date
__________________________________________ _______________________________________________
Address of Individual Assisting Phone No. of Individual Assisting
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State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
UTILITY INFORMATION RELEASE FORM
(APPLICANT)
I, _____________________________________ hereby, authorize ______________ and/or Hawaii Gas to release
information on my utility account; past, current, and future to the Department of Human Services of the State of Hawaii
and the _________________________________________________.
I understand that this information will be used only to provide information for the administration of the Low Income
Home Energy Assistance Program (LIHEAP).
Nam
e: __________________________________________________________
Address: _________________________________________________________
Account number: __________________________________________________
Signature: ________________________________________________________
Date: ____________________________________________________________
__________________________________________________________________________________________________
SUBSCRIBER’S UTILITY INFORMATION RELEASE FORM
(NOT APPLICANT)
___________________________________________ is responsible for my utility account with ______________
(applicant name)
and/or Hawaii Gas. I understand he/she is applying of assistance with the Low Income Home Energy Assistance Program
(LIHEAP). I also understand that as an applicant for LIHEAP verification of my utility account, past current and future
with ______________ and/or Hawaii Gas must be completed.
I authorize the ______________ and/or Hawaii Gas to release information on my account; past, current and
future to the Department of Human Services of Hawaii and _________________________________________________.
Su
bscriber’s Name: __________________________________________________________
Subscriber’s Address: _________________________________________________________
Account number: ___________________________________________________________
Subscriber’s Signature: ________________________________________________________
Date: _______________________________________________________________________
You must provide a picture ID with your signature for verification.
If you have any questions regarding this form, please contact the Community Action Agency that serves your island:
Hawai`i Island HCEOC: (808) 961-2681 ext. 108
Kaua’i KEO: (808) 245-4077
Maui MEO: (808) 249-2970 Hana: (808) 243-4342 Moloka`i: (808) 553-3216 Lāna`i: (808)565-6665
O`ahu HCAP: Central (808)488-6834 Kalihi-Pālama (808) 847-0804 Lēahi (808) 732-7755 Leeward (808) 696-4261
Windward (808) 239-5754
L-3 05/2020
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State of Hawaii Benefit Employment & Support Services Division
Department of Human Services Low Income Home Energy Assistance Program (LIHEAP)
DECLARATION OF ACTIVE UTILITY ACCOUNT
LIHEAP offers two programs Energy Crisis Intervention (ECI) and Energy Credit (EC).
Energy Crisis Intervention assists household who are faced with utility (electric or gas) termination/disconnection.
Benefit for this program is limited to a one time only payment for eligible charges which is deposited into the utility
account. If the household’s bill is greater than the maximum ECI benefit amount, the household is responsible for the
balance of the bill.
Energy Credit assists eligible households with their utility bills. If eligible, a one-time only payment is deposited into the
utility account. Payments are dependent on each household’s situation and LIHEAP funding. Eligibility for this program
also requires the household to maintain an open account with the utility company until the day the credit is applied; and
credit is not transferrable between islands. If there is no open account on the day the credit is posted, the household is
not eligible for the benefit. It is important the household continue to pay their bills until notification that credit has
been received by the utility company.
Energy Credit applications are taken once a year.
Households are limited to one program (ECI or EC) per Federal Fiscal Year
(October 1
st
through September 30
th
).
I have been informed of the requirements above and I choose to apply for:
__________________________ with ___________________________________
(EC or ECI) (Utility Company)
I understand I shall not be eligible for Energy Credit (EC) if I do not have an active residential service account open for
my household on the day the utility posts the Energy Credit. The account number must be active on the day the utility
company posts the Energy Credit. The active account must be with the utility company on the island where my request
was filed. Should the account close after the credit has been applied to my utility account, any unused funds may be
returned to the State.
______________________________________________
Signature
__________________________________________
Print Name
__________________________________________
LIHEAP Worker
______________________________________________
Date
Original to Applicant
Copy to case file
L-4 (08/19)
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Form 2020: complete all sections and questions, sign (Hawaii)

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Completed 19 July 2020

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