APPLICATION FOR UTILITY BILL ASSISTANCE

SECTION II: ADDITIONAL HOUSEHOLD MEMBERS
Provide information for other members of the applicant's household. All household members aged 18 or older must verify their SSN. List additional members on a separate sheet. DO NOT INCLUDE THE APPLICANT IN THIS SECTION.
Household Member 1
Household Member 1 First & Last Name
Household Member 1 relationship to applicant
Household Member 1 Date of birth

MonthDayYear
Date
Household Member 1 Age
Household Member 1 Gender
Household Member 1 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 1 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 1 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 1 Employed?
Please enter "Yes" or "No"
Household Member 1 Social Security Number
Please enter "Yes" or "No"
Household Member 2
Household Member 2 First & Last Name
Household Member 2 relationship to applicant
Household Member 2 Date of birth

MonthDayYear
Date
Household Member 2 Age
Household Member 2 Gender
Household Member 2 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 2 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 2 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 2 Employed?
Please enter "Yes" or "No"
Household Member 2 Social Security Number
Please enter "Yes" or "No"
Household Member 3
Household Member 3 First & Last Name
Household Member 3 relationship to applicant
Household Member 3 Date of birth

MonthDayYear
Date
Household Member 3 Age
Household Member 3 Gender
Household Member 3 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 3 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 3 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 3 Employed?
Please enter "Yes" or "No"
Household Member 3 Social Security Number
Please enter "Yes" or "No"
Household Member 4
Household Member 4 First & Last Name
Household Member 4 relationship to applicant
Household Member 4 Date of birth

MonthDayYear
Date
Household Member 4 Age
Household Member 4 Gender
Household Member 4 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 4 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 4 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 4 Employed?
Please enter "Yes" or "No"
Household Member 4 Social Security Number
Please enter "Yes" or "No"
Household Member 5
Household Member 5 First & Last Name
Household Member 5 relationship to applicant
Household Member 5 Date of birth

MonthDayYear
Date
Household Member 5 Age
Household Member 5 Gender
Household Member 5 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 5 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 5 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 5 Employed?
Please enter "Yes" or "No"
Household Member 5 Social Security Number
Please enter "Yes" or "No"
Household Member 6
Household Member 6 First & Last Name
Household Member 6 relationship to applicant
Household Member 6 Date of birth

MonthDayYear
Date
Household Member 6 Age
Household Member 6 Gender
Household Member 6 Race
Please enter 1 for American Indian or Alaska Native, 2 for Asian, 3 for Black or African American, 4 for Native Hawaiian or other Pacific Islander, 5 for White, 6 for Multiracial, 7 for other or 8 for unknown.
Household Member 6 Ethnicity
Please enter A for Hispanic, Latino or Spanish Origins, B for Not Hispanic, Latino or Spanish Origins and C for Unknown
Does Household Member 6 Receive Disability?
Please enter "Yes" or "No"
Is Household Member 6 Employed?
Please enter "Yes" or "No"
Household Member 6 Social Security Number
Please enter "Yes" or "No"
SECTION III: HOUSEHOLD INCOME
WORK INCOME: List anyone in your household (18 and older & not a full-time student) who has work income (includes self-employment, babysitting, & other odd jobs). List additional information on a separate sheet, if necessary. ATTACH PROOF OF INCOME.
Work income 1

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Work income 2

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Work income 3

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Work income 4

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Work income 5

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SECTION III: HOUSEHOLD INCOME

Rows	NAME	HOW OFTEN PAID	GROSS AMOUNT LAST MONTH	EMPLOYER NAME
1
2
3
4

NON-WORK INCOME: List anyone in your household who receives any of the following and ATTACH THIS PROOF OF INCOME: Alimony | Child Support | Housing Utility Assistance Payment | Retirement Benefits | Social Security Income (SSA) | Supplemental Security Income (SSI) | Supplemental Security Disability Income (SSDI) | TEA | Unemployment Benefits | Veteran's Benefits | Worker's Compensation | Any other non-work income (Use separate sheet, if necessary)
Non-work income 1

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Non-work income 2

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Non-work income 3

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Non-work income 4

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Non-work income 5

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Rows	NAME	HOW OFTEN PAID	GROSS AMOUNT LAST MONTH	INCOME PROVIDER
1
2
3

LAST EMPLOYMENT: If you or any adult (18 or older) member of your household is unemployed at the time of this application, list the most recent employment below. List additional information on a separate sheet, if necessary.

Rows	NAME	WHERE LAST EMPLOYED	WHEN EMPLOYMENT ENDED
1
2

Additional information is required if the household has NO INCOME. Speak with the LIHEAP agency accepting your application.
SECTION IV: RENTER UTILITY INFORMATION (OWNERS SKIP TO SECTION V)
I RECEIVE A REIMBURSEMENT, SUBSIDY, OR ALLOWANCE FOR UTILITIES
If you are a renter and your utilities are included in your rent, provide your landlord's information and a copy of your lease agreement or other documentation reflecting responsibility for paying utilities.

If you are not a renter, please enter N/A.
Renter/ Landlord documentation reflecting responsibility of paying utilities (skip if this does not apply to you)

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LANDLORD'S NAME
LANDLORD'S PHONE
LANDLORD'S EMAIL
RENT PAYMENT:
WHICH UTILITIES ARE INCLUDED IN YOUR RENT? (CHECK ALL THAT APPLY)

SECTION VII: ADDITIONAL SERVICES
WEATHERIZATION ASSISTANCE PROGRAM (WAP)

For more information, visit: www.adeq.state.ar.us/energy/incentives/wap
I want to be referred for weatherization services:
I want to be referred for emergency HVAC repair or replacement only:
ASSURANCE 16 PROGRAM (A-16)
I am interested in attending workshops to learn more about how to reduce my home energy needs and other life skills, such as prioritizing household:
SECTION VIII: APPLICANT'S RIGHTS AND RESPONSIBILITIES
IF SUBMITTING A PAPER APPLICATION, IT MUST BE SIGNED AND DATED OR YOUR APPLICATION WILL BE DELAYED.
- I understand that my application will be shared with the providers of the above selected additional services.
- I understand the information on this application will be kept confidential and only be shared as indicated. No information will be sold, loaned, rented or otherwise disclosed except as indicated on this application.
- I understand that I have the right to appeal any decision regarding this application which I consider improper, any delay in decision or delivery of services, and any disagreement with benefit amount.
- I understand that I must help establish my eligibility by providing as much information as I can about my circumstances.
- I authorize the LIHEAP agency to share information relating to my application with my utility service provider(s) to determine my eligibility or benefit amount.
- I give permission to the Arkansas Energy Office (AEO) to use information provided on my application for purposes of reporting, research, evaluation, and analysis of the program.
- I authorize my utility supplier (s) to release my account information to Arkansas Energy Office (AEO) or its designee (s).
- I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be responsible for monitoring or taking any steps to ensure that the LIHEAP agency maintains the confidentiality of the data or uses the data as I have authorized.
- I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political belief.
- I understand that my signature on this application authorizes the agency to verify information about me or
- any household member and/or use it as a release to secure information needed to determine my eligibility for services.
- I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding me and/or household members, I must repay the cost of any assistance and may face penalty of criminal prosecution.
- The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury.
Applicant's Signature
Date

MonthDayYear
Date
Authorized Representative's Signature
Date

MonthDayYear
Date
LIHEAP 9495 R 10/2025
Should be Empty:

APPLICATION FOR UTILITY BILL ASSISTANCE

COMPLETE THE APPLICATION AND ATTACH THE FOLLOWING DOCUMENTS

SECTION I: APPLICANT INFORMATION

SECTION II: ADDITIONAL HOUSEHOLD MEMBERS

Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

SECTION III: HOUSEHOLD INCOME

SECTION IV: RENTER UTILITY INFORMATION (OWNERS SKIP TO SECTION V)

SECTION V: TYPE OF ENERGY ASSISTANCE

CRISIS DETERMINATION

CRISIS SITUATION

SECTION VI: HOME UTILITY SUPPLIER INFORMATION

PRIMARY HEATING SOURCE (IF OTHER THAN ELECTRIC)

SECONDARY HEATING SOURCE (IF APPLICABLE)

SECTION VII: ADDITIONAL SERVICES

SECTION VIII: APPLICANT'S RIGHTS AND RESPONSIBILITIES