LIHEAP Application | Lower Elwha Klallam Tribe

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Lower Elwha Klallam Tribe

Low Income Home Energy Assistance Program

The amount of payment assistance is calculated by taking into consideration the information that is provided in this application. You will be notified by mail of approval/award amount or denial. • Please answer all questions. If you need assistance filling out this form, help can be provided to you. This application cannot be processed if it is returned incomplete or without all required verifications you will be notified of additional information needed. The application will be denied and a new application will need to be submitted if there is no contact for 30 days. • If you believe we have a copy of your ID, SSI Card and Tribal ID/CIB please confirm with the receptionist. We are only able to reuse Picture ID, Tribal ID/CIB and SSI Cards that are on file. Income must be updated yearly. • Return your completed application and necessary verification documents to the Lower Elwha Klallam Tribe Social Services Department (3080 Lower Elwha Road; Port Angeles, WA 98363) OR by Fax 360.457.8429.

Fraud

To report concerns of possible fraud, waste, or misuse of LIHEAP Funds, please help us eliminate it by calling to report concerns to the LEKT Social Services Director. If you don’t feel comfortable calling our office, you can report it to the Healthy and Human Services Fraud Alert hotline at 1-800-HHS-TIPS (800-447-8477) or the Department of Commerce LIHEAP Administrators by calling 360-725-2857.

What Energy Assistance are you Requesting?(Required)

Please select which heating assistance you would like your award to pay.

Electric

Fire Wood

Crisis

Date

Applicant Name(Required)

First Last Suffix

Date of Birth(Required)

Applicant Tribe(Required)

Lower Elwha

Other

SSI Number(Required)

Gender(Required)

Female

Male

Prefer not to answer

Do you have a disability?(Required)

Yes

Physical Address(Required)

Street Address Address Line 2 City WA ZIP Code

Mailing Address

Street Address Address Line 2 City State ZIP / Postal Code

Phone Number(Required)

Message Phone

Email Address(Required)

Type of Housing(Required)

Own

Rent

How many people live in your home ?(Required)

Do you receive income?(Required)

Earned or unearned income

Yes

Income Types

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Have you applied for LIHEAP with another agency?(Required)

If you answer "yes" you must provide a letter from the agency showing that your application for assistance was denied to be eligible with LEKT LIHEAP.

Yes

A Zero Income Form is required for anyone 18 and older with no income to report.

If one or more individuals has No income, a Zero Income Form is required for each person 18 and over.

LIHEAP Fiscal Year (10/01-9/30)(Required)

Check all that apply. Income is required for the three months prior to the month of your application.

I have been meeting my basic living needs for food, shelter and utilities in the following way:

If a friend or relative is helping pay your bills, please list name(s) and phone number(s)

Food

Shelter

Utilities

No Income Signature

Please sign if you have no income.

Household Member 2

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H2 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child SUpport

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 3

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H3- Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 4

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H4 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 5

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H5 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 6

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H6 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 7

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H7 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount Received?

Household Member 8

Name(Required)

First Last Suffix

Date of Birth(Required)

SSI Number(Required)

Relationship to HOH(Required)

Gender(Required)

Female

Male

Prefer not to answer

Is this person disabled?(Required)

Yes

H8 - Does this person receive income?(Required)

Earned or unearned income

Yes

Income Types(Required)

Wage/Salaries

SSI Benefits

TANF

Per Capita Payments

Child Support

Veterans Benefits

Other

How Often?

Weekly

Bi-Weekly

Twice a Monthly

Monthly

Amount

Required Documents

Upload a clear photo of any additional required documents here(Required)

Tribal Enrollment Verification, Picture ID (all adults), Income Verification, Landlord Statement,

Drop files here or

Max. file size: 50 MB, Max. files: 10.

Landlord Statement

This is required document to determine LIHEAP Eligibility. Please complete the following information.

The following information can be transferred from my application to my housing landlord statement.

Check all that apply

Head of Household Name & all Contact Information

Current Housing Situation

All the household members listed on the application

Landlord Agency / Landlord Name(Required)

Landlord Phone Number(Required)

Housing Section Signature

ZERO INCOME STATEMENT

CERTIFICATION

I certify that all information that I have provided is true and complete. I authorize the LIHEAP staff to verify any information necessary. I realize false or incomplete information may subject me to denial of benefits and prosecution within the limits of the law. I understand that I may appeal a denial for benefits of the amount determination within 30 days of each notice. I further understand that my application will be acted on and I will be notified of the outcome within 10 business days of applying. I understand that even though I may meet the eligibility requirements, I may not qualify for LIHEAP assistance because funding is not available/has ended for the year. My signature on this application further authorizes the utility vendor(s) identified in this application, my landlord and any individual or agency who can verify income or assistance that I, or anyone listed as a member of my household on this application, have received, to release this limited information to the Lower Elwha Klallam Tribe Social Services Department.

Account holder, applicant or authorized representative Account information

Landlord Name(Required)

Electrical Utility Vendor Name(Required)

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Water Utility Vendor Name

CERTIFICATION

PLEASE READ THE INFORMATION BELOW, INITIAL EACH SECTION TO ACKNOWLEDGE THAT YOU UNDERSTAND THE INFORMATION PROVIDED IN THIS SECTION, AND SIGN THE APPLICATION. If you do not fully understand any of the certifications listed, wait to initial until after a LEKT Social Services staff member has explained this in greater detail. Your initial and signature indicate you fully understand.

APPLICANT RESPONSIBILITY(Required)

I understand and acknowledge that I am responsible for providing complete and accurate information to LEKT LIHEAP coordinators, cooperating with LEKT Social Services staff, including, if necessary, LEKT Fraud Investigation Unit.

FAIR HEARING RIGHTS(Required)

I understand that I have a right to a fair hearing upon request if my application is denied or if my application is not acted upon with reasonable promptness. To initiate the fair hearing process, contact the Social Services Director, Rebecca Sampson-Weed, at 360-565-7257, Ext 7456.

CONFIDENTIALITY(Required)

I understand and acknowledge that all information given to LEKT LIHEAP coordinators for the purpose of establishing eligibility is confidential and may not be released to a third party unless I sign a separate notarized release of information form.

RELEASE OF INFORMATION(Required)

I authorize the LIHEAP staff to contact other agencies to obtain the information necessary to determine eligibility for LIHEAP assistance.

FRAUD PENALTIES(Required)

I realize false or incomplete information may subject me to denial of benefits and prosecution within the limits of the law.

ASSISTANCE(Required)

I understand my household is eligible to receive LIHEAP and CRISIS Assistance one time per fiscal year. To the best of my knowledge, I have not nor any member of my household has applied for LIHEAP with any other agency in accordance to the current fiscal year (10/1/22 thru 9/30/23)

Application Signature(Required)

I certify that all information that I have provided is true and complete. I realize false or incomplete information may subject me to denial of benefits and prosecution within the limits of the law. I understand that even though I may meet the eligibility requirements, I may not qualify for LIHEAP assistance because funding is not available/has ended for the year. My signature on this application further authorizes the utility vendor(s) identified in this application, my landlord and any individual or agency who can verify income or assistance that I, or anyone listed as a member of my household on this application, have received, to release this limited information to the Lower Elwha Klallam Tribe Social Services Department.