LIHEAP PARTICIPANT ASSESSMENT APPLICATION

The application process begins the date your completed and signed application and all

supporting documents are received.

Fuel Details - Please provide details on how you heat your home.

Heating/Cooling System(s) and Water Heater Details - Please provide details about these systems within your home

If you believe you have been discriminated against because of race, color, sex, handicap, national origin, religious creed, or political belief, you can file a complaint. Complaint forms are available from the address listed below or at the assistance provider listed above.

DEPARTMENT OF HEALTH AND WELFARE CIVIL RIGHTS AFFIRMATIVE ACTION SECTION PO BOX 83720; BOISE, ID; 83720-0036

If your application for assistance is denied, you will be notified in writing of the reason for the denial. If you are dissatisfied with this decision or feel you have been discriminated against in any way, you have thirty (30) days from the date the notice is mailed in which to request a fair hearing using form HW 0406. If you file a fair hearing request, you will have a right to find out if your eligibility for the LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM and/or LOW-INCOME WEATHERIZATION ASSISTANCE PROGRAM was incorrectly determined according to State and Federal law and policy.

Under Section 3(e3) of the Privacy Act of 1974, 5 U.S.C. 552 a(e3), each agency that maintains a system of records shall inform each individual from whom it solicits information of the authority which permits the solicitation of the information; whether disclosure is voluntary; the principal purpose for which the information is intended to be used; the routine uses which may be made of the information; and the consequences, if any, resulting from failure by the individual to provide the requested information. This statement is required by the Privacy Act to be furnished prior to the collection and use of the information requested. You may retain this statement for your records. Authority: The specific authority for the maintenance of this report is in sections 416 and 417 of the Energy Conservation and Production Act, Pub. L. 94 385. These sections direct Federal and State agencies, which are sponsoring these programs, to monitor the effectiveness of the programs, and to require the local Non-Profit agency implementing the programs to keep records to enable program monitoring. Your responses to the request for information are entirely voluntary, however should you decline to provide the information requested, you will not be considered for assistance. Please initial each of the four items below if you agree with each

Participant Certification - Please initial each line and sign below to certify the accuracy of the information you provided

Under penalty of perjury, I certify that the information contained in this application is true and correct. I understand that I am applying for federal benefits and I could be sanctioned and required to return any benefits I receive if I willfully misrepresent and/or conceal facts. Sanctions may include administrative, civil, or criminal against me, including prosecution.