Application for Energy Assistance

Transcription

1 Office Location: 194 Alimaq Drive Mailing Address: 3449 Rezanof Drive East, Kodiak AK Phone: (907) Fax: (907) What is LIHEAP? The Low Income Home Energy Assistance Program (LIHEAP) helps keep families safe and healthy through initiative that assist families with energy costs. What is AKHAP? The Alaska Heating Assistance Program (AKHAP) helps households pay a portion of their home heating expenses. How do I apply? Fill out this application form completely and as thoroughly as possible. Turn in completed application form and all required documentation to the Community Development Division at KANA. You may apply for benefits from more than one program with the same application. Required Documentation Identification, Income, and Expense Requirements to Process Benefits: Required for every household member. * 12 MONTHS OF INCOME DOCUMENTATION REQUIRED FOR SEASONAL OR SELF-EMPLOYED Copy of Certificate of Indian Blood Copy of Social Security Card Copy of Driver's License or State Identification Card - Adults only Copy of Energy Bill (Most Recent) Copy of Electric Bill (Most Recent) Verification of Tribal Dividends for last month * Income Verification for last month (pay stubs) * Signed Statement of Truth Worksheet Signed Rights and Responsibilities Worksheet Signed Release of Information Worksheet Next Steps in Application Process: Your application will be processed by Program Case Manager You will be contacted with the results of your application Page 1 of 8

2 Program applying for? (Check one program) Energy Assistance (Pays a portion of home Energy costs) I am out of fuel or have a disconnect notice for within 48 hours (Attach disconnect notice) Birthdate Who are you? Name: First, MI, Last of Birth: Male or Female Social Security Number: Mailing Address: City State ZIP US Citizen or Qualified Alien Physical Address: City State ZIP Daytime Phone: Message & or Cell Phone: (Optional): Your Ethnicity/Racial Heritige (Optional): Alaska Native Caucasian Alaska Indian Asian Please Circle one: Hispanic Pacific Islander Other Household Members MI, Last) (First, Household Members List all individuals living in your home. If you need more space, attach another sheet of paper. Relation (NR= t Related) Social Security Number US Citizen or Qualified Alien (/) Received income last month? How Much? Are there any other persons living with you that are not listed above? If yes, List the names of roommates or other persons living at this residence and describe how rent and utilities and expenses are shared. Are you or anyone in your household? Legally Disabled Age 60 or over Receiving Public Assistance 1 Page 2 of 8

3 Have you or any of the adults in your household applied for Energy Assistance through the state of Alaska this year? Income in your Household Examle of how to report income: Application signed in: Provide proof of all income received in: September August October September vember October December vember January December February January March February List all you income from the month prior to the date you signed your application. Without proof, your application may be delayed or denied. Acceptable proof includes: pay stubs showing gross income and year to date figures, an employer work statement or signed letter form your employer, a year end statement or award letters are requried for Social Security and retirement benefits. BANK STATEMENTS ARE NOT * YOU MUST ATTACH A COPY OF THE SOCIAL SECURITY CARD AND PICTURE ID OF THE HEAD OF HOUSEHOLD* Type of Income Codes WA Wages TT Tribal TANF SEA FC Foster Care Payment WC Worker' Compensation SE BIA BIA General Assistance BP Bingo/Pulltab Winnings ATAP SL Student Loans UI Unemployment DI CS Child Support/Alimony TI Tips and Gratuities SSI APA Adult Public Assistance RI Rental Income PFD VB Veteran's Benefits FLS Family Support CO SSA Social Security GR General Relief OT IN Interest PE Pension Household Members Type of Income Gross Income Form of Proof Seasonal Work - Includes Commerical Fishing Self-Employment - Includes Commerical Fishing AK Temporary Assistance Native/Corporation Dividends Supplemental Security Income Permanent Fund Dividend Cash Out of Retirement/Pension Other Last Day of work Weekly? Monthly? 2 Page 3 of 8

4 Employer Name: Employment Phone # Does anyone have income from seasonal / self-employment? *SEASONAL/ SELF-EMPLOYMENT INCLUDES COMMERCIAL FISHING* Does anyone in your house receive rental income from property? If your household inocome does not cover basic living expenses, explain how you are paying these costs. Rent: Utilities: Food: Questions about your residence: What kind of housing do you live in? Check the box that applies. Apartment or Condo House Travel Trailer Hotel Duplex 2 units Cabin Van or Car Hostel Triplex 3 units Renting a room Truck Board Home 4 or more units Studio/efficiency Mobile Home Group home Boat Motel If you live in a trailer or mobile home 35 fee or more, what is the exterior length: Feet Width How many bedrooms are in your home? How much do you pay for rent or mortgage each month? Rent Mortgage Is your rent based on 30 % of your income (subsidized or section 8)? If yes, attach a copy of your rental housing worksheet. We may need to contact your landlord or manager to get information to process your application. Name of Landlord: Address: Phone Number: 3 Page 4 of 8

5 What is your main source of heat? (Check only one. If you have more than one, check the one you use most). Natural Gas Fuel Oil Electric Kerosene Coal Propane Wood Other If you heat with wood, do you harvest it yourself? Who pays for your home heat? If other please explain: Self Landlord Other Who pays for your electricity? Self Landlord Other If other please explain: If you pay both heat and electricity, would you like part of your grant sent to your electric account? *Attach copies of your most recent fuel and electricity bills, or wood vendor receipts.* If heat is included in your rent, attach a copy of your rental agreement and most recent rent receipt or a statement from your landlord showing heat is included in your rent. Please tell us the name of your fuel and or electric company Name of Fuel Company Account Number Name on Account Current Bill Name of Electric Company Account Number Name on Account Current Bill If your account for fuel is in someone else's name, please explain: 4 Page 5 of 8

6 Signature Statement of Truth To receive assistance, you must agree to all of the statements below and sign this form. I understand that I must notify Energy assistance within 10 days if I move or if household members change I understand that a KANA representative may call my home and may contact other people in order to verify my eligibility for assistance. I also understand that information I give may be verified by computer cross matching with other agencies. I authorize the Alaska Department of Labor to release to KANA, information about my eligibility for unemployment insurance and work history. I authroize KANA to communicate with my vendor(s) and other agencies on my behalf as it realates to the Energy Assistance Program. I understand that I must live in the home for which I am applying. I have read the Rights and Responsibilities and the Release of Information sections of the application and I understand them. Including fraud and penalties, as described in this application. I certify under penalty of perjury, or of unsworn falsification in violation of AS , that the statements made regarding the persons in my home and the income and all other items that pertain to my possible eligibility for benefits are true and correct to the best of my knowledge. Verification (by KANA staff) of False statements or, altered or false documentation pertaining to the application, may result in the application being barred from applying for LIHEAP benefits for up to two (2) years and/or be required to reimburse KANA for funds received by Fradulent activity. I understand the first five (5) pages must be included at the time this application is submitted for processing. The sixth page titled "Your Rights and Responsibilities for s Kodiak Energy Assistance Program" is for you to keep for your records. Additionally, I understand processing of this application will be delayed if the application is not complete and all supporting documentation is not provided on the date of submission. 5 Page 6 of 8

7 Rights and Responsibilities for KANA Energy Assistance Program What if I disagree with your decision? Any person whose application is denied or not acted upon with reasonable promptness, or whose benefits are reduced or terminated, has a right to a fair hearing. You may request a hearing by telephone, in person, or in writing. Contact KANA's office or write to the Energy Assistance Program. Hearing requests must be made within 30 days after you are mailed a notice of decision on your Energy Assistance case. At the hearing you may represent yourself. You may also be represented by legal counsel (e.g., Alaska Legal Services Corporation) or by another person of your choice. How are my rights protected? person in the United States, on the ground of race, color, national origin, or disability, shall be excluded from participation or be denied benefits of federal assistance. If you feel you have been discriminated against, you may file a complaint with the Division of Public Assistance or with the United States Department of health and Human Services. Do I need to tell you if something changes?. t having current information may delay your benefits. It is very important that you report changes in your address, phone number or in household members moving into or out of your home within 10 days. Report changes to the Energy Assistance KANA office at (907) or in Juneau at (907) or all other areas toll free or at liheap@alaska.gov What happens if I do not follow the rules? Any member of your household who deliberately breaks any rules and receives benefits to which they are not entitled must repay the benefits and may be prosecuted. 6 Page 7 of 8

8 Release of Information Your signature on this application gives, Department of Health and Social Services and the Department of Law permission to ask for information about your finances, family and personal history. This information is only used in the administration of the Energy Assistance Program and will not be released to any other person or agency outside of the Department of Health and Social Services. The Release of Information will be in effect while you are an applicant or recipient of Energy Assistance and for any later investigations of your eligibility and receipt of benefits. The people or organizations that may be contacted include, but are not limited to: Fuel and Electric Companies Alaska Housing Finance Corporation Kodiak Island Housing Authority Department of Labor and Workforce Development Department of Law Department of Military and Veterans Affairs Department of Revenue U.S. Immigration Services Employers Landloards Native Corporation Private individuals Social Security Administration Tax Assessors 7 Page 8 of 8