For_Office_Use_Only

Date Received:

Enter the date a completed and signed application is received in the county social service office. This is the date which will later be entered on the computer "Household Data" screen as 'Date of Application.’

Case Number:

The use of a case number for LIHEAP is NOT mandatory. However, if no case number is used, the two-digit county identification number MUST still be entered on the computer "Household Data" screen. The case number must include at the beginning the two-digit identification number of the county.

Part I

Name:

Enter the name of the head of the household.

Social Security #:

Enter the Social Security number of the head of the household. If the applicant has no social security number, leave it blank and request that a "dummy" number be assigned by the State Office and the county informed.

Phone, Address, County:

Enter for the home to be heated.

Length of Residence:

Self explanatory. This is to help the county identify households who may have applied previously or in another county.

Race, Sex, Age:

Complete for the head of the household ONLY. This section is for reporting purposes only. If an applicant refuses to complete it, he cannot be required to do so. There will be special codes to handle unavailable information on the computer "Household Data" screen.

Part II

Household Members:

The head of the household should NOT be listed again in this section. All other members of the household should be listed. Again, information regarding age cannot be required, but it is important to obtain this information if the applicant is willing because it is necessary to identify the age of the oldest member of the household for reporting and other administrative purposes. Obtaining the social security number is not mandatory unless it is needed to assist in the income verification process.

Do you currently receive or have you recently applied For (Check X, if yes) Medical Assistance, General Assistance Food Stamps, Child Care Assistance Housing Assistance, TANF.

Disability:

This question is also for reporting and administrative purposes only and cannot be required if the applicant objects to answering it. The definition of handicapped or disabled is included in the definitions section of this manual. (See 05-05)

Part III

Income:

Check "yes" or "no" to each type of income, enter the amount of income, and indicate whether it is received weekly, monthly, quarterly, or annually.

It is not necessary to identify which members of the household have income; however, the income from all members of the household must be included in this section.

Part IV

Assets:

Check "yes" or "no" to transfer of assets (see 25-10-35)

Check "yes" or "no" to each type of asset listed and give the amount. The assets listed must be the total assets held by all members of the household. It shall be the responsibility of the county social service office to decide which assets are not counted.

Part V

Type of Home:

Be sure one of these is checked, as it is needed to determine the amount of benefits.

# of Bedrooms:

This is to include the number of rooms in the living unit which are designed to be sleeping areas. Indicate the number of bedrooms on each floor. If, however, the apartment does not have a separate sleeping room such as in some "efficiency" apartments which have only a "hide-a-bed" in the main living area, the home would count one bedroom. The number of bedrooms establishes the size of the dwelling for purposes of finding the average cost of heating from the cost/consumption tables.

Own/Rent:

Check whether the household rents or owns its living unit.

Include Heat:

Check whether the rent payment includes the cost of heating. If the rent payment DOES include the cost of heat, the ONLY information completed in Part VI will be the type of fuel, which is needed to compute benefits. The applicant in these cases receives a DIRECT payment rather than a payment through a vendor.

Rental Assistance:

If the renter DOES receive rental assistance, it will be necessary to evaluate as described in 20-10-30 whether this household is eligible for the purposes of this program.

Amount of Rent:

Indicate amount of rent tenant pays per month.

Landlord’s Name:

Provide landlord’s name, address, phone.

Part VI

Type of Heat:

The type of heat should be that which the applicant expects to be using the balance of the heating season. (NOTE: This is the ONLY question in this section which must be completed if the applicant is a renter whose rent payment includes the cost of heat -- See Part VI.)

If more than one type of fuel is used, label which type is the "primary" source of heat. If a primary source cannot be identified, benefits will be established using the type of heat which is the more costly. Both primary and secondary heat sources will be identified on the computer "Household Data" screen.

Non-residential:

Non-residential Besides providing heat for your house, does this source provide fuel and/or power for any other buildings, machinery, vehicles, or any other uses, yes or no.

Shut-Off Notice/Need Fuel:

These two questions are to assist the county social service board in determining when an application must be processed under the emergency procedures outlined in 15-05-20.

Supplier name, address:

This should be the supplier of the primary source of heat that the applicant intends to use for the balance of the heating season.

Name on Bill:

Enter the name of the household member whose name is on the heating supplier’s account.

Account #:

This should be obtained if at all possible whenever the supplier uses customer account numbers. It is mandatory for Xcel Energy, MDU, Ottertail, and Ferrellgas.

The applicant must provide copies of ALL heating bills, paid or unpaid, incurred since October 1 of the current fiscal year, for which a Miscellaneous payment will be made. (See 35-20-10.)

Part VII

Weatherization:

Weatherization and Other Services to:  If you are determined eligible your signature on this application will permit the Community Action Agency in your area to contact you with information about weatherization services that can save you money on energy costs.  There is no cost to you, and you are under no obligation. Community Action Agencies also offer other services which may be of help to you. The Self Reliance Program can help you with budget counseling and other needs.  Energy Share can help with non-heat utility bills in emergency situations. Ask your county worker for more information.

Would you like to request that

your furnace be cleaned?  Q Yes Q No

If YES, please specify the vendor you would prefer ______________

Would you like to have

your chimney cleaned? ¨ Yes ¨ No

If YES, please specify the vendor you would prefer _______________

Part VIII - Expenses

Medical:

Check "yes" or "no" to any medical expenses incurred since the previous June 1. Proof of the expenses must be provided. See 25-05-05-05 for the complete list of allowable expenses.

Alimony:

Check "yes" or "no" to alimony/child support paid and provide the amount.

Child Care

Check "yes" or "no" enter the amount, and indicate how often (weekly, monthly, etc.) it is paid. NOTE: child care eligible for deduction must be related to work, education, or training.

Part IX

Reimbursements:

Asks the applicant if he/she has paid for any fuel delivered since October 1. The county should review the applicant’s responses to determine if reimbursements may be appropriate.

Certification and

Authorization to

Release Information:

The county social service office should draw the attention of the applicant to the certification statement whenever there is a face-to-face or telephone contact. When the application is received in the mail, and there is any indication that the applicant may not understand the full implication of his responsibilities as stated in the certification statement, the county worker should contact the applicant and discuss the applicant responsibilities with him.

This does not include confidential protected health information.  This statement was added because this release does not cover medical information that LIHEAP must request.  SFN 1059 must be used to receive medical information.  

Signature:

The application must be signed by a member of the household before the application can be approved.

Worker Signature (if no signature on SFN 530):

This must be signed by worker after determining eligibility for case if SFN 530 was not signed.

Right to Appeal:

The county social service office representative should briefly give the applicant a verbal explanation of his rights to appeal and should draw his attention to the written statement of his rights to appeal which will be mailed with his "Notice of Action."