Low Income Home Energy Assistance Application

Date *

Date

Name

First Name Last Name

Home Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Contact Number

Area Code Phone Number

Birth-date

Date

Tribal Affiliation *

Additional household members:

Name

Date of Birth

SSN

Member1

Member2

Member3

Member4

Member5

Member6

Member7

Any household members 55 or older?

Yes No

Any household members handicapped or disabled?

Yes No

Any household members 6 or younger?

Yes No

Check the type of energy used in the home

Electric Propane/Gas Wood

Do you have a SHUT OFF NOTICE? If Yes please FAX notice to (530)242-4580

Yes No

NOTE: Please send all required documentation to katrina.perry@reddingrancheria-nsn.gov The requirements include: Tribal Verification for at least one member in the house, Identification and copies of SSN’s for all adults, Birth certificates and copies of SSN’s for all children, proof of all adult income, and energy bill.

Please mention income for each household member

Name

CAL Works

SSI

Employment/Income Source

Dollar Amount

Member 1

Member 2

Member 3

Member 4

Member 5

Member 6

Member 7

Total Household Income(in dollars). Please FAX income verification to (530)-242-4580 *

For example 1500

I consent to the verification of the information contained on the application including ALL household income, any benefits received from the Passport to Services/TANF Program at the Department of Human Services of the Tribal TANF Program, Social Services (Disability & Retirement) and all other sources of all income eligibility. I waive my rights to keep these records confidential from Redding Rancheria Tribal Government LIHEAP in order to administer this program. Any adult in the claim must provide proof of income and sign the application. Exception: Staff may determine exceptions for married and non-married households and/or if a catastrophic (fire, flood, earthquake, etc.,) event occurs.

I have read and understand the consent on income information, confidentiality waiver and penalty provision on this application. I understand and agree that you may contact any and all listed sources of income for verification as necessary.

I certify, by signing this application, that all information given is true and accurate. I am also aware that giving false information may subject myself of access to this program for up to three (3) years.

Signature *

Clear

Please verify that you are human *