Low Income Home Energy Assistance Program

Social Services Program

Serving the Oklahoma Counties of Beckham, Blaine, Canadian, Custer, Dewey, Ellis, Kingfisher, Major, Roger Mills, Washita, and the city of Woodward.
Low Income Home Energy Assistance Program
Low Income Home Energy Assistance Program

&

Low Income Household Water Assistance Program

2023 FY

Weatherization Disbursement

If your household is directly responsible for water, heating or cooling costs, you may apply for the LIHWAP/LIHEAP Utility Assistance. A surplus of funds from the cooling and heating season was used to buy individual AC window units and portable heater units. These AC window or portable heater units are being disbursed to several communities across the Cheyenne & Arapaho Tribes’ Service Area. This is a one-time disbursement, and future disbursements are not guaranteed.

In order to qualify for the LIHEAP program, at least one (1) household member must be a member of a federally recognized American Indian or Alaska Native tribe. Also, households must show a financial need based on federal income guidelines. Additionally, all households must provide complete financial information so that the LIHWAP/LIHEAP caseworker may determine the applicant’s eligibility. If this information is not provided, the LIHWAP/LIHEAP caseworker will not process the application, and the applicant will not receive any assistance.

Below is a checklist of the required documents that are needed to process an application. It is the applicant’s responsibility to provide all necessary documents. In order to expedite your application process, please provide all necessary documents when turning in an application. The LIHWAP/LIHEAP Caseworker CANNOT process an application without all required documents.
Applicant is applying for:*

Water Utility AssistanceElectric/Propane/Gas Utility AssistanceWeatherization (cooling or heating equipment)
Have you received any Utility Assistance from Oklahoma Department of Human Services?*

YesNo
When?

MonthDayYear
Date
Do you reside within the 11 county service areas?*

YesNo
Are your utility services currently disconnected?*

YesNo
Has your household received a Heater/Blanket/E-kit?*

YesNo
LIHEAP/LIHWAP REQUIRED DOCUMENTS
CDIB for at least one (1) member of the household:*

Browse Files

Cancelof
Current, Original Utility Bill (Water, Electric, Propane, or Gas)*

Browse Files

Cancelof
Proof of Income for all Household Members over Eighteen (18) Years of Age**

Browse Files

Cancelof
*Applicants Name must match the name on the utility bill

*Check stubs, SSI/SSA/VA award letters, TANF award letters, unemployment benefit statements, child support award letters, & an annual IIM account summary must be included in the proof of income.

All no-income statements must be signed in front of notary. Download and print the form by clicking here.
In order to expedite your application process, please provide all necessary documents.

Please Read Carefully:

The amount of assistance that you receive is determined based on the information that you provide below. Please make sure that all information is accurate and up-to-date. The application must be fully completed, signed, and turned in with all necessary documents to the Cheyenne & Arapaho Tribes Social Services office. Processing will be done in a timely manner and all applicants will receive notice of approval or denial. Please contact the LIHEAP Caseworker if you need assistance filling out an application or if you have any questions.
Applicant

***Must Be Head of Household***
Date:

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Social Security Number*
Email*
example@example.com
Home/Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
List All Household Members
List Household Members (click "add member" to add members until all members are added)
Household Income

Please provide a complete, accurate list of income for all members of your household.
All household members over eighteen (18) years of age must provide proof of income
Income
Please list any assistance that you receive:
Assistance
I, name currently
do not receive any income from any employment sources or other sources at this time.
How long have you been unemployed?   Date
Client Signature:   Signature
Date:   Date
*Please attach any award letters above in the income section for benefits received*
PLEASE READ CAREFULLY

By signing below, I agree to the following terms:
I certify that the information on this application is true and correct to the best of my knowledge. If I provide fraudulent information, my eligibility for future LIHEAP services could be suspended. *

Agree
I understand that my application will not be processed until all required documentation is submitted. *

Agree
I understand that my application will take up to 3 work days to process or up to two (2) weeks for vendor checks to be processed by A.P. department.*

Agree
I authorize the Cheyenne & Arapaho Tribes’ Department of Social Services to acquire any information that is necessary to complete my application. *

Agree
I understand the Cheyenne & Arapaho Tribes’ Social Service Program is not responsible for damage or repair to heater/ac units and/or fans.*

Agree
Comments?
Date

MonthDayYear
Date
REQUIRED DOCUMENTS:

CDIB for at least one (1) member of the household

Current, Original Utility Bill (Electric, Propane, or Gas)

Proof of Income for all Household Members over Eighteen (18) Years of Age*
*Applicants Name must match the name on the utility bill

*Check stubs, SSI/SSA/VA award letters, TANF award letters, unemployment benefit statements, child support award letters, & an annual IIM account summary must be included in the proof of income. All no-income statements must be signed in front of notary.
If you have read, understand, and agree to the terms above, please sign below*

Clear
Have you used LIHEAP/LIHWAP in the past?

YesNo
Would you or your family be interested in attending events focused on DIY weatherizing of your home?

YesNo
Would you like to see more educational information on reducing energy costs?

YesNo
Would you be interested in attending budgeting classes?

YesNo
In which age category do you belong?

18-2930-4950-5960 years or older
How many are in your household size?

1-32-55 or more
What are some ideas you would like to see with the LIHEAP/LIHWAP program?
Other Comments/Ideas:
Should be Empty:

Social Services Program

Low Income Home Energy Assistance Program

LIHEAP/LIHWAP REQUIRED DOCUMENTS

All no-income statements must be signed in front of notary. Download and print the form by clicking here.

In order to expedite your application process, please provide all necessary documents.

Please Read Carefully:

Applicant

List All Household Members

Household Income

PLEASE READ CAREFULLY