Form

LIHEAP Applicant Demographic Information
Household Information
County of Residence
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?
If Yes, please provide name(s).
Benefits Received - Please include checkboxes for all that apply:
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 1
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 2
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 3
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 4
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 5
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 6
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 7
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 8
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
Additional Household Member 9
Name

First NameLast Name
Gender
Marital Status
Education - Highest Grade Completed
Work Status
Health Insurance
If your household has more than 10 members, a UETHDA representative will contact you to collect information for any additional household members.
Should be Empty:

LIHEAP Applicant Demographic Information

Household Information

Additional Household Member 1

Additional Household Member 2

Additional Household Member 3

Additional Household Member 4

Additional Household Member 5

Additional Household Member 6

Additional Household Member 7

Additional Household Member 8

Additional Household Member 9