Indiana Energy Assistance Program Application Part 1. Personal Information

Transcription

1 INSERT AGENCY LOGO Indiana Energy Assistance Program Application Part 1. Personal Information Your Name Date of Birth First MI Last Social Security Number MM-DD-YYYY Current Home Address: Street or PO Box/Apt # City State Zip Code County: Best Contact Phone Number Other Contact Phone Number: Primary Language spoken at home: address: Part 2. Household Information List ALL household members, starting with you. Attach a separate sheet for any additional household members. First Name, MI, Last Name Social Security Number Date of Birth MM- DD-YYYY Race Hispanic Sex M/F Disability Years of school (over 23 years only) Veteran Has Income Has health insurance Is anyone in your household currently an employee or board member this local service agency?

2 No Yes: If yes, please circle one: Self Staff Board Member Part 3: Income, Benefits, and other Assistance: Please list all income from all members of your household aged 18 and up. Income includes but is not limited to wages, social security, pension, veteran s benefits, disability, self-employment, workers comp etc. For a complete list of income see instructions. You must send proof of income. _ How many people age 18 or up did not have income the past 3 months? (Please fill out a Zero Income Affidavit and an Indiana Workforce Development Release of Information for EACH person) Do you pay Child Support? Monthly amount Paid: (include proof of payments) Do you receive: Food Stamps? Yes No Do you receive TANF? Yes No If eligible, would you like to be referred the weatherization Program? Yes No Part 4. Energy Emergency If you are having an energy emergency such that you are disconnected, about to be disconnected, or out of fuel, please contact your local service provider. If you don t know who your local service provider is, please call 211. Calling your local service provider will ensure faster service than mailing in your emergency with this application. Already disconnected. Company: Disconnect Date: Amount Owed: Received disconnect notice. Company: Date Scheduled: Amount Owed: In crisis Bulk/Biofuel: You are in crisis if you have less than 25% of your fuel left in your tank or biofuels (wood, pellets etc.); or if you are within ten (10) days of running out of your primary heating source. % of fuel do in your tank today Amount Owed: You must self-declare that you are in crisis for bulk and biofuel. Please call your local service provider for the Self- Declaration of Primary Fuel Source Level or download it from eap.ihcda.in.gov.

3 Part 5. Housing Information Please check the type of housing you live in: Single Family House Multi-Unit (Apartment/ Condo) Mobile Home Life Estate Other: Renters: Please provide lease, or Landlord Affidavit Landlord s Name: Phone Address: Is heat included in your rent? Is electricity included in your rent? Yes No Yes No If heat or electricity is included in the rent, we may pay you directly. You will have to provide a lease or Landlord affidavit showing that utilities are in the Landlord s name. Please provide your Direct Deposit information on the ACH/Direct Deposit form which can be found at eap.ihcda.in.gov Homeowners: Do you own your home, are you buying your home or have a Life Estate? (Please provide proof of ownership) Yes No Part 6. What is your Primary Heat? Bulk Fuels (Kerosene, LP Gas, Oil, Wood, Coal, Pellets) Electricity Natural Gas What energy company (s) supply heat and electricity to your home? Primary Heating Source Vendor Electric Vendor Company Name Name on Account Account Number Send a copy of your last heat and electric bill. For Bulk fuel, you may send a fuel receipt but it is not required. If the name or one of your household members name is not the name on the account, call your local service provider. If your bills are in your landlord s name, include a lease or a Landlord Affidavit. Part 7. Consent and Signature By signing below, I certify that all information provided is correct and true. My signature also certifies that I have read and agree to the Privacy Notice Statement, Social Security Number Disclosure Statement, Client Release of Information Statement and Certification of Information Statement attached to this application. Please read the Your Rights and Responsibilities document which you can find at eap.ihcda.in.gov or attached to this document. If you do not understand the information in this document, or need help, call the local EAP Service Provider. To obtain a list of local service providers, please call 211 or Liheap@ihcda.IN.gov, or go to eap.ihcda.in.gov. Privacy Notice : Privacy Notice and Your Rights and Responsibilities Privacy Act Provisions: Federal laws require us to tell you about your rights and responsibilities before we collect and use information about you that is classified as private or confidential. This form provides you with important information that complies with the federal Privacy Act of 1974, 5 U.S.C. 552a(e)(3).

4 Please read this Privacy Notice carefully before completing and signing the Indiana Energy Assistance Program application, and keep this Privacy Notice in your records for future use. This Privacy Notice applies to the Energy Assistance Program (EAP) and the Weatherization Assistance Program (WAP). Why do we collect the information on the application? We will use your information to research, evaluate and administer the EAP and WAP programs. We need the information: To know you from other individuals. To see if you qualify for assistance. To allow us to get federal or state funds for the assistance you receive. To meet federal or state reporting requirements. Do you have to give us the information? You have the right to not give us the information we ask for. What happens if you give or do not give us the information? If you give us the information requested on the application, your application will be processed. If you do not give us that information: Your application will not be processed. You might not receive services. You might not receive help with energy bills. Your services might be delayed. We will keep whatever information you give us, whether or not your application is approved. Who may see this information? The following persons may receive information contained in your application if: (i) they need access to the application information to do their jobs in connection with the EAP and WAP, or (ii) they are otherwise authorized by federal or state law to receive it, or (iii) they use the information for reports, to measure outcomes, and for referrals and eligibility purposes: Local Energy Programs Service Providers under contract with IHCDA. Program auditors as required or permitted by Office of Management and Budget (OMB) circulars. United States Departments of Health and Human Services and Energy. Persons so authorized pursuant to court order or subpoena. Your energy companies for affordability and Energy Programs. United States Social Security Administration. Lifeline/Telephone Assistance Plan for verifying program eligibility. Other agencies or entities as allowed by federal or state law. Why do we collect Social Security Numbers? We use Social Security Numbers in the administration of the EAP and WAP to assure eligible applicants and their household members receive only allowable benefits. Federal law allows us to require you to disclose your Social Security Number in order to process your application and to prevent, detect and correct fraud and abuse. AUTHORITY: Section 205(c)(2)(C)(i) of the Social Security Act, 42 U.S.C. 405(c)(2)(C)(i). Why do we ask for information about your race? This is voluntary information. It is compiled and recorded for statistical purposes only. The program does not discriminate for reasons of race or ethnic background, religion, gender, sexual orientation or political affiliation.

5 Your Rights and Responsibilities. You have certain rights to get help. You have the right: To apply again after 60 days if you get turned down. To know the rules about we determine if you are eligible. To receive a response within 60 days of submitting all information. To appeal in writing within 10 days to your local service provider after you are sent the results of your application if: You do not agree with the amount of your benefit award. You do not agree with the reason that you were denied. You have these responsibilities: You must tell us if you or any member of your household: Received help with your energy bills earlier this winter. Moved to a new address (tell us within 30 days of the move). Changed your fuel dealer or gas or electric companies. You must pay your heating and electric bills. This program will pay only part of your bills. You must pay the rest. What if you think the facts in your file are wrong? Talk to your local EAP Service Provider about what you think is wrong in your file. What happens if you give false information? The local EAP Service Providers or IHCDA may check and verify any of the information contained on your application or otherwise provided. You may be denied benefits if you provide incomplete or false information. You may be held civilly or criminally liable under federal or state law for knowingly making false or fraudulent statements on your application. How do you appeal? If you think your energy payment was not what it should be or you did not get the services you thought you would, you may contact the local EAP Service Provider listed on the application. If you are not satisfied with that agency s answer, you may write an appeal letter to the IHCDA. Keep a record of when and where you appealed. Ask for Assistance: Call the local EAP Service Provider listed on the application if you do not understand the information in this document. To obtain a list of local service providers, please call IHCDA toll free , Liheap@ihcda.IN.gov, or go to eap.ihcda.in.gov.

6 INSTRUCTIONS FOR COMPLETING INDIANA HOUSING & COMMUNITY DEVELOPMENT AUTHORITY ENERGY PROGRAMS APPLICATION These instructions help you complete your Indiana Energy Programs Application. The application is used to apply for the Energy Assistance Program (EAP) and Weatherization Assistance Program (WAP). The Indiana Energy Programs Application is available in online at eap.ihcda.in.gov. ANY missing information may delay decisions regarding your eligibility and benefit amount. Your application will be processed as quickly as possible, however, in the beginning of the season this could take several weeks. You will receive a letter when your application is completed. Failure to provide required documents may result in delay or denial of your application. To apply for the Energy Programs, you must send to your local EAP Service Provider: The State-issued photo ID for the applicant. Photo IDs are not required for other household members. The completed application with all questions answered and the last page signed and dated. Copies of Social security cards for all members one year or older. A copy of proof of income received in the last 3 full calendar months for each household member. If you paid child support, proof of child support payments made. A copy of your last heating bill and your last electric bill. If you are a homeowner, a copy of your property taxes, mortgage statement, homeowner insurance or deed. If you rent, a copy of your lease or Landlord Affidavit. PART 1. Personal Information: Fill in your Social Security Number (SSN), name, current home address, phone number, and contact information. At least one household member age 18 or older must provide a verifiable SSN to process the application. Contact your local EAP Service Provider if no one in your household is able to provide an SSN. You may be able to provide an alternative legal document number. PART 2. Household Information: Fill in all the information for everyone living in your home. ALL people living in the home are household members if they share the kitchen or other living areas in the home. Non-custodial parents may include their minor children under age 18 as household members. Household information will also include questions about race and years of school. These questions are optional. Do not fill in years of school information for household members under age 24. PART 3. Income, Benefits and other assistance: Sources of Income: List all sources of income for all members of your household, 18 and older. Do not count income for Full time students under age 23. Report all income and all money received by each household member in the last 3 full calendar months. Send proof of all income received by all people in your household in the last 3 full calendar months before the month you sign your application. Send copies, originals will not be returned. Proof of Income by type: Wages: Check stubs or a written statement signed by your employer stating gross wages, or bank statements. Spousal Support or Alimony: Checks, bank deposits, or a note signed by the payer stating the amount and dates of received payments or other proof of amount received. Disability Payments, Veteran s Benefits, Workers Compensation, Social Security, RSDI and SSI: Award letters, bank statements showing direct deposits or a copy of the check(s). Unemployment Compensation: Unemployment weekly benefit printout. Self Employed, Farm, and Rental Income: The first 2 pages of your most recent IRS-1040 tax return and relevant schedules (C, E, F, SE). If you did not file taxes or you have been self-employed less than 2 years, call your local EAP Service Provider and ask for a Self-Employment Form or download the form from eap.ihcda.in.gov. Enter the date your business started in the space provided on page two of the application. Interest, Dividend: Bank statements or your IRS-1099 or IRS Retirement Income: Benefit checks/stubs, bank statements or award letter.

7 Pensions and Annuities: Benefit checks/stubs, bank statements or award letter.no Income: If your household has no income and no one is self-employed, call your local EAP Service Provider for a Verification of Zero Income form and an Indiana Workforce Development Release of Information. You will also find these form on eap.ihcda.in.gov. BOTH forms must be filled out for EACH person claiming zero income. Deductions: You may deduct any child support payments you made to someone else to support your child. Please provide proof of payment. Do you receive Food Stamps or TANF? Please answer yes or no. This is for information only. Food Stamps and TANF do not count toward your income. Weatherization Assistance Program (WAP) Income Eligibility Guidelines You may be eligible for the Weatherization Assistance Program (WAP) even if your household s income is higher than the EAP limits. WAP provides free home energy upgrades to income-eligible homeowners and renters to help save energy and make your home a healthy and safe place to live. Please indicate if you are interested in being referred to the weatherization program. For income eligibility please refer the Indiana Weatherization Assistance Program at eap.ihcda.in.gov or (800) **Please send a copy of your proof of income. Originals will not be returned** You will be eligible for EAP if you are under 150% of the Federal Poverty Level. Your income for 3 months must be at or below these amounts: Househol Income for 3 months Househol Income for 3 months Household Size Income for 3 months 1 $4,523 4 $9,225 5 $10,793 2 $6,090 3 $7,658 6 $12,360 PART 4. Energy Emergency: If you are having an energy emergency such that your energy services are or will be shut-off or you are out of fuel, or almost out of fuel, check type of emergency and send a copy of the notice from your energy company showing the amount owed. For faster help with an emergency, or if you feel you are in a lifethreatening situation, please call 211 or your local service provider, who may be able to assist you more quickly or from being disconnected. PART 5. Housing Information: Check the type of housing you live in and your monthly payment. If you are a renter, tell us whether you pay heat or electricity and your landlord s name, phone number and address. If you cannot provide a lease, please call your local service agent for a Landlord Affidavit or down one at eap.ihcda.in.gov. If your utilities are included in your rent, we will pay you directly. You must provide proof that the utilities are in the Landlord s name by providing the lease or Landlord Affidavit. Homeowners: You are a homeowner if you own, are buying your home, have a home mortgage or contract for deed, or have a Life-Estate. Self-employed: If your residence is used for work or you rent out space in your home, complete this section. Weatherization Assistance Program (WAP) Income Eligibility Guidelines You may be eligible for the Weatherization Assistance Program (WAP) even if your household s income is higher than the EAP limits. WAP provides free home energy upgrades to income-eligible homeowners and renters to help save energy and make your home a healthy and safe place to live. Please indicate if you are interested in being referred to the weatherization program. For income eligibility please refer the Indiana Weatherization Assistance Program at eap.ihcda.in.gov or (800) PART 6. What is your primary heat source? Enter the name of the heating and electric company providing energy to your home. Include the name on the account and the account number. Wood, corn, pellet or other biofuel users: you may leave this blank or enter your regular provider. PART 7. Consent and Signature: Read the permissions carefully. An adult household member, 18 years of age and older or emancipated minor, must sign the application. Any other person signing the application must have be an Authorized Representative or have a Power of Attorney (POA) to actions behalf of the household and must submit a copy along with the application. Return the application to your local EAP Service Provider.