Low Income Home Energy Assistance Program

Utility Assistance/Weatherization Disbursement

If your household is directly responsible for heating or cooling costs, you may apply for the LIHEAP Utility Assistance, Air-Conditioner/Heater, Fan/Blanket & Energy Kit Program. 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 and 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 LIHEAP caseworker may determine the applicant’s eligibility. If this information is not provided, the 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 LIHEAP Caseworker CANNOT process an application without all required documents.

Applicant is applying for: *

Utility Assistance Heater/Blanket/Weatherization Program

Have you received Utility Assistance or Electric Assistance? *

Yes No

When?

Date

Do you reside within the 11 county service areas? *

Yes No

Are your utility services currently disconnected? *

Yes No

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

Yes No

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

Browse Files

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

Browse Files

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

Browse Files

*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.

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.

Date:

Date

Name *

First Name Last Name

Date of Birth *

Date

Age *

Social Security Number *

Email *

example@example.com

Home/Service Address *

Street Address

Street Address Line 2

City

Postal / Zip Code

Mailing Address (if different from above)

Street Address

Street Address Line 2

City

Postal / Zip Code

Phone Number *

Area Code Phone Number

Name *

First Name Last Name

Date of Birth *

Date

Age *

Social Security Number *

Relation *

Employed? *

Yes No

Elderly, Handicapped, or Disabled?

Elderly Handicapped Disabled

Is there anyone else in the household not added to this application? *

Yes No

Name

First Name Last Name

Date of Birth

Date

Age

Social Security Number

Relation

Employed?

Yes No

Elderly, Handicapped, or Disabled?

Elderly Handicapped Disabled

Is there anyone else in the household not added to this application?

Yes No

Name

First Name Last Name

Date of Birth

Date

Age

Social Security Number

Relation

Employed?

Yes No

Elderly, Handicapped, or Disabled?

Elderly Handicapped Disabled

Is there anyone else in the household not added to this application?

Yes No

Name

First Name Last Name

Date of Birth

Date

Age

Social Security Number

Relation

Employed?

Yes No

Elderly, Handicapped, or Disabled?

Elderly Handicapped Disabled

Is there anyone else in the household not added to this application?

Yes No

Name

First Name Last Name

Date of Birth

Date

Age

Social Security Number

Relation

Employed?

Yes No

Elderly, Handicapped, or Disabled?

Elderly Handicapped Disabled

All household members over eighteen (18) years of age must provide proof of income

Name

First Name Last Name

Hourly Wage

Payment Schedule

Weekly Monthly Bi-Weekly Annually

Name

First Name Last Name

Hourly Wage

Payment Schedule

Weekly Monthly Bi-Weekly Annually

Please list any assistance that you receive:

Source of Assistance:

Award Amount

Payment Schedule

Weekly Monthly Bi-Weekly Annually

Source of Assistance:

Award Amount

Payment Schedule

Weekly Monthly Bi-Weekly Annually

*Please attach any award letters above in the income section for benefits received*

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 a week to process or up to two (2) weeks for vendor checks to be processed. *

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

If you have read, understand, and agree to the terms above, please sign below *

Clear

Have you used LIHEAP in the past?

Yes No

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

Yes No

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

Yes No

Would you be interested in attending budgeting classes?

Yes No

In which age category do you belong?

18-29 30-49 50-59 60 years or older

How many are in your household size?

1-3 2-5 5 or more

What are some ideas you would like to see with the LIHEAP program?

Other Comments/Ideas:

Social Services Program