FY 25 IMPACT - LIHEAP Application

IMPACT Low-Income Home Energy Assistance Program (LIHEAP)
The Low-Income Home Energy Assistance Program (LIHEAP) is a program that is designed to help low-income families with winter heating costs. If approved, a family will have protection against disconnection until April 1st, 2025. Households may also receive a one-time payment towards their heating bills.

Applicants will need to provide the following documentation:
- IDs for all household members
- A copy of their most recent heating and electric bill
- Proof of gross income for all household members from ONE of the following time frames*:
  - Past 30 days
  - The most recent 12 months
  - The past calendar year
*All income must be from the same time frame. Please select one of the options and submit all applicable documentation.

Please fill out all the required information and upload all appropriate documents. Documents must be clear and easy to read for a speedy application review process. Incorrect information and incorrect or poorly uploaded documents can delay your application process.

If you have questions or issues with the application process, please contact us at energyassistance@impactcap.org or call 515-518-4770.
What IMPACT service county do you live in?*

Boone County, IowaJasper County, IowaMarion County, IowaPolk County, IowaWarren County, IowaOther
You must live in one of IMPACT's service counties in Iowa to use this online application. If you do not live in Boone, Jasper, Marion, Polk, or Warren County, please use this link to find your local community action agency.
Do you have a disconnect notice from your heating or electric provider?*

YesNoI have already been disconnected
ATTENTION: To assist with restoring your services as quickly as possible, please call or text 515-518-4770 or email energyassistance@impactcap.org immediately and inform our staff that your services have been disconnected.

We discourage continuing with your online application if your services have already been disconnected. If you choose to continue applying online please be aware that there will be a delay in the processing of your application.
What date is your disconnect scheduled for?

MonthDayYear

Contact Information
Phone Number:*
What type of phone number is this?
Email
Residence Address (This address must match a utility bill or lease):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different from your residence address?

YesNo
Mailing Address (optional):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Residence Information

Please provide the following information about your housing situation.
Do you own or rent your home?*
What are your mortgage or rent costs per month?*
What type of home do you live in?*
What is your heating source?*
Are you receiving monthly assistance through another program and you are only responsible for a portion of the rent?*

YesNo, I am responsible for the full rent
Do you pay for your heating through your rent payments?*

YesNo
Do you pay for your electric through your rent payments?*

YesNo

Do you have savings over $50,000, that you can access without penalty?*

YesNo


Landlord Name:
Landlord Phone Number:
Landlord Email:

Utility Vendor Information

Heating Bill Information*


Utility company name:
Account number:
Name on account:

Please upload a copy of a recent HEATING BILL*

The photo/scan of the utility bill must include: Utility company name, account holder name, and account number
Cancelof
Is your electric bill account information the same as above?

YesNo, I have different account information for my electric

Please upload a copy of a recent ELECTRIC BILL*

The photo/scan of the utility bill must include: Utility company name, account holder name, and account number
Cancelof

Certification Statement
Please certify that you understand the following and sign:

I am hereby making application for the Low-Income Home Energy Assistance Program (LIHEAP), I understand that my signature or my verbal consent gives permission to the agency processing this application to use the information I have provided to determine my household's eligibility for these programs and for other programs administered by this agency for which I have applied. Further, I hereby give permission to the State of Iowa, the U.S. Department of Energy, U.S. Department of Health and Human Services, and the agency processing this application to obtain additional information from my energy supplier about my household usage and payment history. I also give permission to the State of Iowa to release application information to my energy supplier and to provide details about my account and usage to the LIHEAP Assistance Programs as necessary to facilitate the receipt of benefits.

My signature on this application or my verbal consent certifies, under penalty of the law, the following:

1) All information and documentation associated with this application is accurate and complete to the best of my ability.

2) I declare I am the only person in the household who has or will apply for these programs.

3) I understand that any willful misrepresentation of the information provided is subject to program disqualification and penalty of law.

4) If applicable, I authorize the weatherization of my house at no cost to me or my family. This includes authorizing the agency to contact my landlord for permission to weatherize the home when applicable. I understand that signing this application does not guarantee I will receive weatherization assistance
Please sign below:*

Clear
Typed Full Name:*

First NameLast Name
Application submission date:*

MonthDayYear
Should be Empty:

Income Type	Documentation Accepted
Employment Income	Paystubs from all employers
Social Security (Supplemental, Disability, or Retirement)	Award letter, check copy, bank statement, or check copy showing most recent deposit
Pension, Retirement Income, or Veterans Benefits	Award letter, check copy, bank statement, or check copy showing most recent deposit
Child Support	Bank Statement, Iowa DHS statement, court documents
Adoption Subsidy	Copy of check or monthly statement
Unemployment Income	Bank Statement, Iowa Workforce Development "white sheet"
Self Employment	Monthly Ledger, Self Attestation
Other Income	Any documentation that shows the recipient's name, date of payment, and gross income amount

IMPACT Low-Income Home Energy Assistance Program (LIHEAP)

Contact Information

Head of Household Information

More questions about you:

Please tell us about your other household members*:

Residence Information

Utility Vendor Information

Income & Non Cash Benefits

Certification Statement