Housing & Human Services Department Community Acton Agency 400 South Varr Avenue Telephone: (321) Cocoa, Florida Fax: (321)

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1 Housing & Human Services Department Community Acton Agency 400 South Varr Avenue Telephone: (321) Cocoa, Florida Fax: (321) Thank you for your interest in the Brevard County Low Income Home Assistance Program Energy (LIHEAP). You must fall into one of these categories to be given priority during the first week of the month. ELDERLY: Must be at least sixty (60) years old. DISABLED: Must be receiving disability benefits from either Social Security Administration or employer/insurance disability benefits. HOUSEHOLDS WITH CHILDREN UNDER THE AGE OF FIVE (5): Must provide Birth Certificates for children five (5) years old or younger. APPROVED FAMILY SELF-SUFFICIENCY PROGRAM: Actively participating in the Family Self-Sufficiency Program. You will need to complete the enclosed application and return it with the following information listed below. Please also see the attached. Completed application (Note: on the first page of the application, the column next to name asks for applicant number, this is your social security number. This must be completed in order to process application). Florida Drivers License or Florida Identification Card for all adult household members with a Brevard County Address. Original Social Security Cards for all household members. Birth Certificates for all children that are listed on the application. Verification of all household income for the past 60 days. If you are receiving Unemployment Compensation Benefits you will need to call for a payment history for the past 60 days. If you are receiving Social Security, SSI, SSD, Pension, Alimony, Annuity, AFDC/TANF, Retirement, Workman s Comp, VA, Child Support, or Etc. you will need to provide a current printout for the past 60 days. A Self Declaration Form must be completed by all adult household members that have zero income or self employment for the past 60 days. Copy of electric/gas energy bill and a current yearly lease. **Incomplete applications will not be accepted You must have all documents. If you have any questions, or we can be of any assistance, please feel free to contact us at (321)

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3 LIHEAP ASSISTANCE APPLICATION FOR OFFICE USE ONLY ( ) Home Energy 1. Give the following information for the applicant first, then ( ) Summer Crisis for each person living in your home. If more than seven (7) ( ) Winter Crisis people live in your home, list the additional people on a ( ) Weather Related separate piece of paper, giving the same information and attach it to this form. (Please print neatly and do not fax application) DATE STAMP NAME (First, Middle, Last) Applicant Number Date of Birth Sex Race Relationship To Applicant SELF Source Of Income** Monthly Income **Source of Income: wages, self-employment, social security, child support, regular gifts, unemployment compensation, retirement benefits, SSI, TANF/WAGES, pensions, and interest on savings, etc. 2. If your annual household income is less than 50% of the poverty guidelines, explain how you pay for food, shelter, clothing, transportation and home utilities. 3. Are you: Renting (apartment or home) OR own/purchasing your home? 4. How many disabled persons live in the household? 5. If you share your living or mailing address with others who are not part of your household, list their names: ; ; ; 6. If you, or anyone in your home, are not a U.S. citizen or an alien lawfully admitted for permanent residence, give the person s name and alien status under the Immigration and Naturalization Act. Name: Alien Status: Name: Alien Status: 7. Are you, or any member of your household, a member of the Porch Creek Indian Tribe? YES NO 8. Does anyone in your household have any Health Insurance? YES NO (Please check which one) Private Medicaid Medicare Healthy Kids Stay Well Kid Care Other Page 1 of 3

4 LIHEAP ASSISTANCE APPLICATION (Continued) 9. The address where you are living:, FL, Number and Street Name; RFD or Lot # City of Town Zip Code County 10. Your mailing address, if different from above:, FL, Number and Street Name; RFD or Lot # City of Town Zip Code County 11. Day time telephone number where you can be reached: 12. Check the programs that anyone in your household is currently eligible for or receiving assistance from: [ ] CSBG [ ] Weatherization [ ] Food Stamps 13. If you, or any member of your household, have received Low Income Home Energy Assistance Program (LIHEAP) or Emergency Home Energy Assistance for the Elderly Program (EHEAP) in the last 12 months, complete the information below: Name of Agency Type of help (home, crisis, elderly, weather related) Date Name of Agency Type of help (home, crisis, elderly, weather related) Date Verified by Staff: 14. Do any of the following situations currently apply to you? (Check appropriate box below.) [ ] My electricity has been disconnected. [ ] I have little or no propane, fuel oil or wood for heat. [ ] My current electric bill is delinquent. [ ] I have a shut-off notice from my gas company. [ ] I have a shut-off notice from electric company. [ ] My current natural gas bill is delinquent. [ ] None of the above currently apply to my [ ] Other energy crisis describe below. household. 15. If your cost of home energy is included in your rent, give the name and telephone number of your landlord. Attach a copy of a letter from the landlord confirming that your rent includes utilities. Landlord: Landlord s Telephone Number: ( ) 16. If you live in a government subsidized housing complex, Section 8 housing, dormitory, nursing home, adult foster home, or any kind of group living facility, complete the following: Name of the place where you live:, FL, Number and Street Name; RFD or Lot # City of Town Zip Code County Page 2 of 3

5 LIHEAP ASSISTANCE APPLICATION (Continued) 17. Provide the following information about the primary source of energy you use to heat your home. Give only one (1) company. Energy Source Company s Name Customer s Name on the Account Customer s Account Number Company s Telephone # Electric Natural Gas Propane Fuel Oil Wood Other Specify: 18. Provide the following information about the primary source of energy you use to cool your home. Energy Source Company s Name Customer s Name on the Account Air Conditioning Fans Customer s Account Number Company s Telephone # 19. If not given above in questions 17 or 18, provide the following information about your electric company. Company s Name Customer s Name on the Account Customer s Account Number Company s Telephone # 20. Attach a copy of your current bills for all companies listed above in questions 17, 18 and 19. FRAUD STATEMENT: The information above is, to the best of my knowledge, true and complete. I understand that priority in providing assistance will be given to those households with the lowest income and greatest need; i.e., those households in which the elderly, disabled, medically needy or where children reside. I authorize the agency to make benefit payments directly to my energy supplier. I am aware that after I have provided all the information requested, if I am applying for Crisis Assistance, the Agency has 48 hours (18 hours if my situation is life threatening) to approve or deny my application; and, if I am applying for Home Energy Assistance, the Agency has 45 days to approve or deny my application. I am also aware that if I am not approved or denied within the time allowed, or not approved for the correct amount, I have a right to an appeals hearing. APPLICANT S SIGNATURE DATE ELIGIBILITY SPECIALIST DATE SUPERVISOR/EDIT STAFF DATE Page 3 of 3

6 Housing & Human Services Department Telephone: (321) Community Action Agency Fax: (321) South Varro Avenue ocoa, Florida BREVARD COUNTY HOSUING & HUMAN SERVICES COMMUNITY ACTION AGENCY SELF DECLARATION OF INCOME I,, hereby certify that I am unable to provide written documentation of my income due to the following reason(s): I CERTIFY THAT THE INFORMATION I HAVE DISCLOSED IS TRUE AND ACCURATE. I UNDERSTAND THAT INTENTIONALLY PROVIDING FALSE INFORMATION TO OBTAIN FINANCIAL ASSISTANCE IS GROUNDS FOR DENIAL OF ASSISTANCE, AND MAY BE GROUNDS FOR PROSECUTION UNDER FLORIDA STATUES OR Client Signature Date

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