2025-2026 IMPACT - LIHEAP Application

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

Proxy Form

You indicated at the beginning of this application that it was being completed via a proxy. Please answer the following questions to disclose required information in order to be a valid proxy application. IMPACT staff may contact either party to confirm information.
Name of Proxy*

First NameLast Name
Relationship of Proxy to LIHEAP applicant*
e.g. Parent, Sibling, Power of Attorney, etc.
Other relevant information you would like to disclose:
If you are employeed by a caregiver organization, please indicate the organizations name and any other relevant information.
Please read the following statement to both parties and sign:

Be it known that I, the undersigned, hereby appoint the party listed above, whose relationship to me is indicated above, as my proxy to apply on my behalf for programs and services related to the Low Income Home Energy Assistance Program (LIHEAP).

This proxy designation only applies to the Low Income Home Energy Assistance Program (LIHEAP) and will be in effect for one program year
(October 1 - September 30) from the date of my signature.

I may revoke this proxy at any time by written notification to IMPACT Community Action Partnership.

I understand that I may be contacted by phone to verify the proxy designation each time a program or service is being requested on behalf of the proxy.
Client Signature*

Clear
Date of Client Signature*

MonthDayYear
Date
Client Phone Number*
Please enter a valid phone number.
Proxy Signature*

Clear
Date of Proxy Signature*

MonthDayYear
Date
Proxy Phone Number*
Please enter a valid phone number.

Certification Statement
Application submission date:*

MonthDayYear
Please certify that you understand the following and sign:

I am hereby making application for the Low-Income Home Energy Assistance Program (LIHEAP), and/or the Weatherization Assistance Program. I understand that my signature on this application 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 and Weatherization Assistance Programs as necessary to facilitate the receipt of benefits.

My signature on this application or my verbal consent certifies, under penalty of 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
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How would you rate your experience with completing this application?

1 - Difficult2 - Somewhat Difficult3 - Neutral4 - Somewhat Easy5 - Easy
Tell us about it! (optional)
Can we contact you regarding your experience?

YesNo

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

2025-2026 Low-Income Home Energy Assistance Program (LIHEAP) Application

Is your household eligible to apply in October?

Contact Information

Residence Information

Household Member Information

Head of Household Information

More questions about you:

Please tell us about your other household members*:

Utility Vendor Information

Income & Non Cash Benefits

Self-Declaration of Zero Income

Proxy Form

Certification Statement

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