FOR KAY COUNTY RESIDENTS ONLY

LIHEAP and LIHWAP GUIDELINES AND DOCUMENTS CHECKLIST
Heating and Cooling Assistance/Water Assistance

LIHEAP is designed to alleviate the immediate threat of utility service disconnection (electricity, gas, propane, or heating oil/wood). LIHWAP is designed to alleviate the immediate threat of water service disconnection and help those approved with arrearages.

IMPORTANT: Any unpaid balances from a previous residence, any re-connect fee or deposits of any kind will not be paid.

Application Requirements:

Must be a member of a federally recognized tribe
Must live within the defined service area
Applications CANNOT be put in a child’s name
Must provide Social Security Numbers for applicant and ALL members of the household
Must provide a copy of Driver’s License/Photo ID for ALL ADULT members of thehousehold
Must provide resident verification (if renting, rental agreement from landlord)
Current utility bill and/or disconnect notice
Birth certificates and guardianship papers for ALL non-tribal children in the household

Income Requirements:

Income verification from ALL SOURCES for all members of the household
If you are claiming $0 income, provide statement from DHS, unemployment, etc. statingyour household income and number in residence. Must fill out a Zero Income StatementForm and turn it in with application to be processed

Other Qualifications:

If you have used DHS (LIHEAP) Assistance, you CANNOT receive LIHEAP from thetribe. WE WILL CONTACT DHS AND OTHER TRIBES TO VERIFY.
Must meet the LIHEAP income guidelines to qualify

Date *

First Name *

Last Name *

Social Security Number *

Date of Birth *

Phone *

Mailing Street Address *

Apartment or Suite Number

City *

County *

State *

Zip Code *

Phone Number *

Email Address *

List all household members, including yourself, which live in the home.

1.) Name *

Date of Birth *

Sex *0 / 1

Social Security *

Relationship to Applicant *

Ethnicity/Tribe *

2.) Name

Date of Birth

Sex0 / 1

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

3.) Name

Date of Birth

Sex0 / 1

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

4.) Name

Date of Birth

Sex0 / 1

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

5.) Name

Date of Birth

Sex0 / 1

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

6.) Name

Date of Birth

Sex

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

7.) Name

Date of Birth

Sex0 / 1

Social Security

Relationship to Applicant *

Ethnicity/Tribe *

Public Assistance

Are you or anyone in your household currently receiving any public assistance? *YesNo

If so, check which programs you are receiving assistance from.TANFSSIFood StampsOther

Have you used LIHEAP from any other state or tribe including DHS? *YesNo

Housing Information

Do you own or rent a home? *OwnRent

If you rent, are your utilities included?YesNo

If yes, which utilities are included?

If utilities are included, a statement from the landlord MUST BE submitted that states utilities are included in rent.

No file chosen

Attach landlord statement here.

List all household members who are employed.

Name

Employer

Hours worked per week

Net Monthly Income

USD

Name

Employer

Hours worked per week

Net Monthly Income

USD

Name

Employer

Hours worked per week

Net Monthly Income

USD

Name

Employer

Hours worked per week

Net Monthly Income

USD

List all other sources of income

Unemployment

USD

Employment

USD

Social Security

USD

Disability

USD

Tribal Per Cap

USD

Lease from Land/Rentals

USD

Individual Indian Monies

USD

Child Support

USD

TANF

USD

Alimony

USD

General Assistance

USD

Pension

USD

Veteran's Benefits

USD

Other sources of income

Amount from other sources

USD

What was your household's total NET income for the last 30 days? *

USD

Fuel Information

What is the main fuel type to heat your home? *PropaneGasWoodElectric

What is your primary cooling source? *ElectricityOther

If other please describe.

Energy Company Name *

Account Number *

Name on Account *

If account is not in your name, please explain why.

Fair Hearings Statement

If you wish to appeal any decisions regarding your application:

If you feel the decision of the social services department is in error, you may file a written appeal within ten (10) days after receiving a letter of denial to the Social Services Director.
If you desire a hearing, you may submit a request in writing to the following:

Kaw Nation Social Services Department

PO Box 50

Kaw City, OK 74641

Please Initial Each Line Below

I declare the information on this application is true and correct to the best of my knowledge. *0 / 2

I am a member of a Federally Recognized tribe and have provided proof of enrollment. *0 / 2

I understand that my household must meet income guidelines to qualify for assistance. *0 / 2

I understand it is my responsibility to check with utility company regarding LIHEAP payments received (if approved) and any balances that I may owe. *0 / 2

I understand that it takes a minimum of two (2) weeks for a check to be processed and and sent to the energy provider that I listed in the application. *0 / 2

I have read and understand the Fair Hearings statement above. *0 / 2

I understand that falsifying information on this application can result in denial. *0 / 2

I am submitting my verification of sources of all income and authorize Kaw NationSocial Services staff to obtain necessary verification of information provided in this application. *0 / 2

Applicant's Signature *

Date *

DECLARATION OF INCOME

My name is: *

I do hereby declare that my total household income is: *

USD

The size of my household has the following number of people. *

Applicant Signature *

Today's Date *

Household Size	Annual Income
1	$25,927
2	$33,905
3	$41,883
4	$49,861
5	$57,838
6	$65,816

RELEASE OF INFORMATION

My name is: *

If other, please include below.

Signature of Applicant *

Today's Date *

Sign here to confirm your Duplicate Services Acknowledgment. *

LIHEAP AND LIHWAP APPLICATION

FOR KAY COUNTY RESIDENTS ONLY

LIHEAP and LIHWAP GUIDELINES AND DOCUMENTS CHECKLISTHeating and Cooling Assistance/Water Assistance

IMPORTANT: Any unpaid balances from a previous residence, any re-connect fee or deposits of any kind will not be paid.

Application Requirements:

Income Requirements:

Other Qualifications:

List all household members, including yourself, which live in the home.

Public Assistance

Housing Information

List all household members who are employed.

List all other sources of income

Fuel Information

Please Initial Each Line Below

DECLARATION OF INCOME

RELEASE OF INFORMATION

LIHEAP and LIHWAP GUIDELINES AND DOCUMENTS CHECKLIST
Heating and Cooling Assistance/Water Assistance