Summer Cooling Assistance Program (SCAP) Application

Please List All Household Members

List YOURSELF first:
Name

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
What is your race?
Sex:
Do you have a disability?
Citizenship Status:
What is your MONTHLY INCOME?
Are there additional household members to add?

Household Member #2 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #3 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #4 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #5 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #6 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #7 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?
Are there additional household members to add?

Household Member #8 Full Name:
Date of Birth:

MonthDayYear
Date
Age:
Social Security Number:
Relationship to YOU:
What is this person's race?
Sex:
Does this person have a disability?
Citizenship Status:
What is this person's MONTHLY INCOME?

Additional Documentation

Please upload required documents here:
Identification: Please upload a CLEAR and CURRENT Photo ID for ALL household members over the age of 18.

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Social Security Cards: Please upload SS Cards for ALL household members over 6 months of age:

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Proof of Income: Please provide pay stubs FOR EACH HOUSEHOLD MEMBER over the age of 18 who have earned income. If you are self-employed, please provide a copy of your most recent filed tax return (1040 & ALL Schedules); All other income types: Social Security, SSI, Veteran's Assistance Award Letter or bank statement showing direct deposit amount; proof of pension. Variable income: Paystubs for the last 3 months or year-to-date pay stub. Proof of Unemployment payments, child support, TANF/GA.

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Proof of Citizenship for ALL HOUSEHOLD MEMBERS: For US Citizens: birth certificate, passport/passport card, Native American Tribal Card, Certificate of Naturalization; certificate of citizenship

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Proof of Qualified Alien Status: Lawful permanent resident, cross border NA Indian, asylee, refugee, Cuban/Haitian entrant, paroled in to the US for at least one year; deportation being withheld; battered immigrant spouse/children; victim of trafficking; members of armed services or veterans.

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Utilities: Please upload a copy of your most recent electric bill:

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I certify that I have checked the information on this application and that it is true and correct to the best of my knowledge. I agree to notify the agency of any changes to this application within ten (10) days. I certify that this is the only application submitted from or on behalf of my household. I understand this application will not be completed until ALL necessary documents have been received. If those documents are not received within thirty (30) days, this application will be void. I understand that it is against the law to make false statements and that I am subject to prosecution if I do. I understand my right to a fair hearing if I am dissatisfied with the application process or eligibility decision. I authorize the agency to refer my application to programs within state agencies as deemed beneficial to my household. I authorize the Department of Health & Social Services (DHSS) and its LIHEAP service providers to obtain information about my utility usage and billing history from my vendor(s). I am the customer fo record, customer's authorized agent or an authorized third party for the energy service account identified in this application and I authorize my energy service provider to disclose my customer data.
Applicant Signature:
Date:

MonthDayYear
Date
IMPORTANT!

BEFORE you click SUBMIT, please PREVIEW your form to ensure everything is correct! If you are a RENTER, please PRINT the form and have your landlord complete the Authorization Form. Email or scan this form to scap@firststatecaa.org. If you are declaring ZERO INCOME, please print and sign the Zero Income Declaration form and return to scap@firststatecaa.org.
Should be Empty: