ENERGY ASSISTANCE PROGRAM APPLICATION Please Print Clearly

1HEAD OF HOUSEHOLD APPLICANT INFORMATION

Full Name:
Last / First / M.I.
Address:
Street Address PO Box (if applicable) / Apt/Unit #
City / State / ZIP Code
Contact Phone: / ( ) / Social Security Number:

HOUSEHOLD MEMBERS INFORMATION

Ethnicity Codes
A.  Hispanic or Latino
B.  Not Hispanic or Latino / Race Codes
A.  Black or African American
B.  White
C.  Other
D.  Multi-Race
E.  Native American / Health Insurance Codes
A.  Medicaid
B.  Medicaid Select
C.  Medicare
D.  Other
E.  Hoosier Health Wise
F.  None
G.  Medicare/Medicaid / Income Source Codes
A.  Employment Earnings
B.  Social Security
C.  Temp Assist Needy Families (TANF)
D.  Unemployment Comp
E.  Suppl. Sec Inc. (SSI)
F.  Veteran’s Benefits
G.  Pension / Retirement
H.  Child Support
I.  Interest / Dividends
J.  Self Employment Income
K.  Other:
Household Members
First and Last Name / Relation-ship to HOH / Birth Date / Age / Sex M/F / Social Security Number / Ethnicity
Code / Race
Code / Dis-abled
Y/N / Veteran
Y/N / Last Grade Completed / Health
Insurance Code / Income Source Code
1. / SELF
2.
3.
4.
5.
6.
7.

Please UCircle the Correct Response

1. Do you own or are you buying your home? Yes No

2. Do you rent your home? Yes No If yes, please have your landlord complete the landlord affidavit.

3. Do you currently reside in a: a. House b. Apartment / Duplex c. Mobile Home**

**NOTE: If you own your mobile home and pay lot rent a landlord affidavit is required from the mobile home park.

4. What is your current family situation?

a. Single Parent / Female d. Two Adults/No Children

b. Single Parent / Male e. Two Adults/With Children

c. Single Person f. Other: ______

5. How do you heat your home during the winter? Please include a copy of your most recent utility bills or invoice for LP Gas or Oil and completed utility affidavit.

a.  Kerosene e. Coal

b.  LP Gas f. Electric

c.  Oil g. Natural Gas

d.  Wood

Heat Provider: ______Electric Provider:______

6. Are you currently receiving TANF (Cash)? Yes No

If yes, please provide a 12 month TANF (IQCH) printout.

7. Are you currently receiving Food Stamps? Yes No

8. Have you or any other household members receive Child-Support

in the past 12 months? Yes No

If yes, please provide a 12 month printout.

9. Are any of your utilities cost included with your rent? (Example: Gas or Electric) Yes No

If yes, please include a landlord affidavit.

10. Are you currently on Subsidized Housing? (Example: HUD, Section 8, Public Housing) Yes No

If yes, please include a landlord affidavit

Certification of Information Statement

“I certify that the above information provided is correct and true to the best of my knowledge. I understand that I may be required to verify these statements and give my consent to the agency from which I am requesting assistance to make any necessary contacts to verify these statements. I am a resident of Indiana and an applicant for the Energy Assistance and/or Weatherization Assistance Program(s). I acknowledge any services or materials provided to my household will be a gift without consideration or payment by me. I give permission to the State of Indiana and the agency from which I am requesting assistance to obtain information from my energy supplier about my energy usage and payment history. I understand that the State of Indiana may use information provided on this form for the purpose of research, evaluation and analysis. I hereby release the State of Indiana, the Community Action Agency or other entity from any liability whatsoever resulting from delivery of these activities. I have received no expressed or implied warranties concerning receipt of these services”.

Privacy Notice Statement

This Agency is requesting disclosure of personal information that is necessary to accomplish statutory purpose. IC-4-1-6-2(a)

Social Security Disclosure Statement

This Agency is requesting disclosure of your Social Security number in order to expedite processing of your application.
Disclosure is mandatory. IC 4-1-8-1(a)(3)

Appeal Information

If you are denied and do not agree with the reasons stated, or your application for services is not processed in a timely manner, you may appeal the decision to the Community Action Agency for review. If you are not satisfied with the CAA determination, you may request further review from the State of Indiana by submitting an Applicant Notification form to the Division of Family and Children.

Signature of Applicant: ______Date ______

Relationship of Applicant: ______

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