LIHEAP Application Checklist

LIHEAP Application
Low Income Home Energy Assistance Program Email: LIHEAP@yuroktribe.nsn.us

The Low-Income Home Energy Assistance Program (LIHEAP) helps eligible Yurok Tribal households with heating and energy costs, including electricity, propane, wood, wood pellets, and diesel/kerosene. To qualify, households must include at least one enrolled Yurok Tribal member, meet low-income guidelines, and reside within the Yurok Tribe Service Area. Support is provided directly to energy providers or wood vendors to ensure homes remain safe and warm.
Tribal Verification

Cancelof
Government Issued ID (Driver’s license, State ID, Passport, Tribal ID)

Cancelof
Income Verification for all Household Members 18 years and older (Last 30 days of income, Passport to Services, most recent award letter for Social Security, Retirement, Disability, Unemployment, or Child Support)

Cancelof
Heating Verification (all pages of most recent power/propane bill and/or Quote for Wood Pellets)

Cancelof
Verification of Disability if applicable

Cancelof

Members of the Household & Demographic Info (all individuals within the household):

	Name	Relationship	DOB	Gender (M/F/Other)	Tribal Roll #	Race	Ethnicity: Are you of Hispanic, Latino, or Spanish Origins?
1
2
3
4
5
6
7
8
9
10
11
12
13

Monthly Income (all household members including yourself): *

	Name	Amount
Wages/Employment
TANF/CALWORKS
Social Security/SSI
Unemployment
Veteran Benefits
Pension/Retirement
Other

Monthly Total $ Amount*
Type of Heating Assistance Requested (please choose one):*

Electric:Propane:Kerosene/Diesel Monitor Heater:Pellets:Wood:
If Wood Selected, Fill out the following
Length of Wood (inches)
Wood Preference:

HardwoodFir

LIHEAP- Responsibility Statement
I, Print Name* reside at(Physical Address, City, Zip) *
The utility bill is in the name of Print Name* and I am responsible for payment of the utility bill for the above address.
He/She/They are my (Relationship)
Please briefly explain the reason why you are responsible for the payment of the utility bill for the address above:

LIHEAP Certification & Authorization to Release Information:
Initial Acknowledgment*

I understand, due to limited available funds, turning in an application is not a guarantee of approval, and it is still my responsibility to continue to make my utility payments.
Initial Acknowledgment*

I understand if I email or fax my application to a different email address or fax not listed on this application, it may delay services.
Initial Acknowledgment*

I am the only person in my household who has applied for this program.
Initial Acknowledgment*

I understand that I can only apply for the services listed on this application.
Initial Acknowledgment*

I authorize Client Services staff to speak to my utility company about my account.
Initial Acknowledgment*

I hereby release the Yurok Tribe and its agents and employees from any/all liabilities,responsibilities, damages, and claims that might result from release of information authorized above.

LIHEAP Fair Hearing Statement

Client rights if you wish to appeal any decision regarding your application. If you feel the decision of the LIHEAP Intake Staff is in error, you may file a written appeal within ten (10) days after receiving a letter of denial to the Client Services Operations Manager. The Client Services Department Operations Manager will review and make a decision regarding your appeal within five (5) days after giving the opportunity for both a fair administrative hearing to individuals whose claims for assistance under the plan is denied or not acted upon with reasonable promptness and receiving your written appeal. If the Client Services Department Operations Manager upholds the initial decision, you have ten (10) days after receiving their written decision to file a written appeal to the Client Services Department Director. The Client Services Director then has ten (10) days to receive their final written decision by mail.
Initial* I have read the above rights and have been advised of my rights to appeal any decision made by the LIHEAP Intake Staff.
By Signing this document, I am certifying that all information provided oral and written are true. I acknowledge that such information is subject to verification and that falsification of this information shall be grounds for denial and/or reimbursement of funds received from this program.

This release will be in effect for one year form the date it is signed unless terminated earlier at the request of the client.
Applicant Signature*

Clear
Date*

MonthDayYear
Date
Co-Applicant Signature

Clear
Please verify that you are human*
Date

MonthDayYear
Date
Should be Empty:

LIHEAP Application

LIHEAP Application Checklist

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

Members of the Household & Demographic Info (all individuals within the household):

If Wood Selected, Fill out the following

LIHEAP- Responsibility Statement

LIHEAP Certification & Authorization to Release Information:

LIHEAP Fair Hearing Statement