Low Income Home Energy Assistance Application

NOTE: We are currently out of funds.

Note: All requested information on the application form must be complete and accurate. Failure to provide required information will result in a denial for assistance. Giving false information is subject to penalties of denial of the LIHEAP application, and/or denial of access to the LIHEAP Program and other Community Services Programs for up to three years. If you are denied assistance and wish to appeal the decision, please contact the Director of Community Services. Likewise, if your application is complete and there is a failure to act on it in a timely manner, contact the Director of Community Services By signing the LIHEAP application, you are agreeing that all information is true and accurate.

Date*

Date

Name*

First NameLast Name

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Number*

Area CodePhone Number

Email*

example@example.com

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?*

YesNo

Any household members handicapped or disabled?*

YesNo

Any household members 11 or younger?*

YesNo

Check the type of energy used in the home*

ElectricPropane/GasWood

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

YesNo

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.

NOTE: Please send all required documentation to Breana.Gensaw@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.

NOTE: Please reduce the file size before attaching. Total attachment size should not exceed 19MB.

Please attach any required documentation*

Browse Files

Example: Tribal Enrollment Card

Signature*