HOUSEHOLD TYPE (CHECK ONE)
SINGLE PERSON SINGLE PARENT FEMALE TWO PARENT HOUSEHOLD MULTIGENERATIONAL HOUSEHOLD
TWO ADULTS NO CHILDREN SINGLE PARENT MALE NON -RELATED ADULTS WITH CHILDREN OTHER
For each income sources listed in section 2, you must include proof of income documentation with this application.
For EMPLOYMENT INCOME, provide copies of your check stubs for 30 days proceeding this application, or provide a copy of your federal income tax return
For SELF-EMPLOYMENT INCOME or FARM INCOME, provide a copy of your federal income tax return
HOUSEHOLD NON-CASH BENEFITS
SNAP (Food Assistance) SECTION 8* MUST ATTACH CURRENT TENANT WORKSHEET
WIC (Women, Infants, Children) PUBLIC HOUSING* MUST ATTACH CURRENT TENANT WORKSHEET
LIHEAP (before application) PERMANENT SUPPORTIVE HOUSING
SINGLE HOUSE BUILDING WITH 2-4 UNITS BUILDING WITH 5+ APARTMENTS OTHER
ACCOUNT NAME IF DIFFERENT THAN HEAD OF HOUSEHOLD
7. HOUSING TYPE (CHECK ONE)
8. ELECTRIC COMPANY ACCOUNT NUMBER
9. HEAT SOURCE
ELECTRIC NATURAL GAS OTHER
THE FOLLOWING ARE REQUIRED TO BE SUBMITTED.
• Current month copies of your utility bills (gas and/or
electric)
• Last four consecutive copies of check stubs for all
household members over 18 years old.
• Current Proof of other income (Social Security, Social
Security Disability, Unemployment Insurance, Retirement
and Pension Funds, etc.)
• If Self Employed (Current income tax documents)
• Current Food Stamp Printout (must be printed within 30
days)
• Separation Notice or lay-off slip from previous employer
(if applicable)
• Proof of present address (rent receipt, lease, deed or bill
other than energy bill.)
• Utility allowance, (if applicable) via lease signed resident
worksheet for Section 8 or Tenant Housing
• Copies of Driver’s license or picture ID of head of
household and (his/ her) Social Security card
• Proof of total members living in your household and
copies of their Social Security cards
• Additional information may be required to determine
your eligibility for energy assistance.
• IF receiving contributions as income, complete
contributions statement, available in office or online
• If Zero Income for adults over 18, complete a Zero
income form for each adult, available in office or online
APPLICANT ASSURES THAT:
* I have furnished true and correct information regarding
household
income and agree to promptly report any changes
in the household income or number of individuals living at
the listed address.
* I grant the Agency and the LHC full permission to verify any
and all information with both public and private sources or
any entity, which may have furnished me, services.
* I understand that if I receive services for which I am
ineligible because of false information, I may be required to
repay the LHC.
* I understand that I have a right to request a fair hearing
from the LHC if I feel that the decision regarding services
requested is unfair or that my civil rights have been violated.
The contractor staff person completing this application has
read these assurances to me; I fully understand this
agreement and have been given an opportunity to ask
questions.
* I understand that by signing this document that I attest to
the truth of all information provided (either verbally or in
writing) to the LHC I further,
* Certify that I live at the listed address and am responsible
for payment of utility bills at that address.
* Authorize utility supplier(s) to furnish billing records
AUTHORIZATION TO RELEASE INFORMATION:
I understand that the personal information furnished by me to
process my LIHEAP application for assistance is confidential
information. I understand that providing authorization to release
information is not required for me to obtain services under the
LIHEAP and is strictly voluntary. I authorize Louisiana Housing
Corporation (LHC) to release or disclose all or parts of the information
in my client file to outside sources for the purposes of statistical
YES NO
By signing this application below, I acknowledge that I
have read the above information and certify that all
information that I have stated and documents I have
provided are correct and accurate.
