The Emergency LIEAP WV form is an application designed for individuals seeking assistance with home heating costs in West Virginia. This form allows applicants to provide essential information about their household, income, and heating needs to determine eligibility for the Low Income Energy Assistance Program (LIEAP). Completing the form accurately is crucial for receiving timely support; click the button below to fill out the form.
The Emergency Low Income Energy Assistance Program (LIEAP) form is a crucial document for individuals and families in West Virginia who are facing financial hardships related to home heating costs. Designed by the West Virginia Department of Health and Human Resources (DHHR), this application helps determine eligibility for emergency assistance in maintaining heating services. The form requires applicants to provide identifying information, such as their name, address, and contact details, along with demographic information including race and ethnicity. It also prompts applicants to list any benefits they may currently receive, such as SNAP or Medicaid, which can influence their eligibility for assistance. Additionally, the form includes sections that inquire about the household's living situation, heating methods, and any current heating-related issues, such as disconnection notices or low fuel levels. Applicants must also provide detailed information about all household members, including their relationship to the applicant and their total monthly income. The application process emphasizes the importance of accuracy and completeness, as missing information can lead to delays or denials of assistance. Signatures are required to confirm understanding of the program's terms and conditions, ensuring that applicants are aware of their rights and responsibilities. This form serves not only as a means to access vital resources but also as a safeguard for the integrity of the assistance program.
West Virginia Department of Health and Human Resources (DHHR)
APPLICATION FOR LOW INCOME ENERGY ASSISTANCE PROGRAM (LIEAP)
Regular LIEAP Emergency LIEAP
I. IDENTIFYING INFORMATION
B. Check any benefit being received by you or a member of your household:
SNAP Benefits
WV WORKS
Medicaid
A.Name and Mailing Address of Applicant:
C.
Directions to your home:
Name
Address
City
County
D.
Race (check one or more):
State
Zip
Phone
White
Black
American Indian
Asian
If you do not have a telephone, please supply the name of E. Ethnicity: a relative or neighbor who will take a message for you.
NamePhone
Hispanic
Non-Hispanic
F.List the following information about yourself (Applicant) and ALL persons in your household. This includes family members and all others living under the same roof:
Is this person a
Birth Date
How is this
Social
Total Monthly Income Before Deductions
Full Name
U.S. Citizen?
mm/dd/yy
person related to
Security
the Applicant?
Number
Source or Name of Employer
Amount
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
DFA-LIEAP-1 (Rev. 10/16)
II.HOME HEATING INFORMATION
Instructions: Please check the correct box which applies to your household after each question and enter written statements where required.
A.What is your current living arrangement?
House/apartment/mobile home No shelter/homeless Institution Other (explain)
B.Is anyone in your household disabled or blind?
Yes
No
C.Do you or someone in your household pay for your home heating costs?
If yes, what is the average monthly cost?
If no, who pays?
D.How do you heat your home?
(Check the item which corresponds to your primary source of home heating.)
PLEASE CHECK ONLY ONE.
Natural gas furnace
Liquefied gas (petroleum, propane, etc.)
Coal
Wood or wood products
Electric furnace
Fuel oil or kerosene furnace
Baseboard heat
Space heater (type)
Other
E.Main Heating Source (same source as Question D) Company/Vendor
Account #
Is your heating source included in your rent?
Yes No
Is the name on your heating bill different from the applicant’s name?
If yes, what is the name?
First
Last
Do you share a main heating source with another household?
F.Electric Company/Vendor Account #
Is your electricity included in your rent?
FirstLast
Do you share an electric meter with another household? Yes No
G. Do any of these apply to you today?
Already disconnected
Company name
Received a disconnect notice
Past due bill
Are you low on fuel/wood/coal (less than 3 days remaining)?
Are you out of fuel/wood/coal?
Non-working furnace/ boiler/heat system?
III.SIGNATURES AND STATEMENTS OF LIABILITY
Place a check in the appropriate block with each statement.
I certify that I have read or had read to me all statements
on this form and I do understand all questions. I further
certify that all information given is true and correct to the
best of my knowledge.
I understand I may request a hearing if I am not satisfied
with any decision of the local DHHR office in determining
my eligibility for LIEAP or the amount of benefits
approved, or if I feel that I have been discriminated
against because of race, color, national origin, sex, age,
religious or political beliefs, or because I am disabled, that
I may be represented by an attorney at a fair hearing but
that DHHR or any of its authorized representatives will not
pay for these legal services; and that LIEAP intake will
close without prior notice.
I understand that I may be asked to provide additional
information or verify any or all information entered on this
application form and that I will cooperate by providing
such information as required in determining my eligibility
for LIEAP; and I authorize DHHR to use and share all
such information with other agencies, organizations, or
entities to verify eligibility for LIEAP and the amount of
benefits.
I understand that the date of application is the date I
submit the completed form along with all required
verifications and information, and that missing information
may result in delay and/or denial of LIEAP benefits.
I give my consent for my heating and electric companies
to give data about my account and energy usage to the
West Virginia Department of Health and Human
Resources (DHHR), contractors for the Low Income
Energy Assistance Program (LIHEAP) and the
Weatherization Program.
I understand that if I knowingly provide false or fraudulent
information that is used in connection with the eligibility
determination for LIEAP, I may be subject, upon
conviction, to fines or imprisonment or both. I understand
I will be required to repay benefits received to which I am
not entitled and that my failure to repay such benefits
may result in loss of future LIEAP benefits.
I agree and authorize any bank, financial institution,
governmental agency or department, corporation,
business concern or person to furnish any information
which relates to my eligibility for and receipt of LIEAP to
DHHR or any of its authorized representatives and
understand DHHR may use or share such information to
verify my eligibility for and the amount of benefits.
I understand that I will be notified in writing within 30 days
from the date my completed application is received by
DHHR of the decision made on my application and that I
may request a hearing if I have not been notified within
30 days. If I receive a direct payment, I understand it
must be used to pay for the cost of primary home heating
and that a receipt which verifies my payment for this must
be submitted with my application for Emergency LIEAP. I
understand that if I am found eligible, I am entitled to only
one Regular LIEAP payment and one Emergency LIEAP
payment during the LIEAP season.
MAIL THIS APPLICATION TO YOUR LOCAL DHHR OFFICE ONLY
-NOT TO YOUR HEATING SUPPLIER. YOU MAY ALSO TAKE IT TO YOUR LOCAL COMMUNITY ACTION AGENCY OR SENIOR CENTER.
PLEASE PROVIDE YOUR ELECTRIC BILL and YOUR MAIN HEATING SOURCE BILL WITH THIS APPLICATION. If electric is your main heat source, you will only need to provide the electric bill, otherwise please provide both.
Your Signature
Date
Signature of Person Who Helped You Fill Out This Form
This application cannot be processed unless all information requested has been entered or attached
and it is signed and dated by you and the person who assisted you.
IV.
FOR OTHER AGENCY USE ONLY
IMPORTANT: The Worker MUST ensure this section is completed in its entirety in order for the
application to be complete
Application Received Date:
V.
Name of Other Agency Which Received the Application:
A. Did application include required verifications as specified on instruction sheet? Yes No Indicate how income was verified, as appropriate:
B. Was additional verification requested?
Indicate date application was considered complete:
Signature & Title of Worker from Other Agency
FOR DHHR USE ONLY
A. Was application complete?
If no, what was missing?
Incomplete applications will be denied unless Applicant supplies missing information within 10 days or Worker is able to obtain the information within the 10-day period.
B.
Date of Application:
Date of Decision:
Date entered in RAPIDS:
Decision:
Approved
Denied
The date of application is the date the form is received by DHHR or the other agency, or date postmarked if received after LIEAP closes. For emergency Regular LIEAP and Emergency LIEAP, contact with the fuel supplier must be made before approving payment but not before determination of eligibility is completed.
D. Recording (must include account number, account name, and vendor number in CMCC):
E.BIRS completed for Regular LIEAP? Check IQPS to make sure payment is scheduled.
DHHR Worker’s Signature
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