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