HiddenAccepting applicationAs designated in the LEKT LIHEAP Applicaiton the first two weeks of LIHEAP Services are reserved for Elders, disabled and families with children under 5 years of age. Low Income Home Energy Assistance ProgramThe 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.FraudTo 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 MM slash DD slash YYYY Applicant Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY Applicant Tribe(Required) Lower Elwha Other SSI Number(Required) Gender(Required) Female Male Prefer not to answer Do you have a disability?(Required) Yes No Physical Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific WA ZIP Code Mailing Address Street Address Address Line 2 City State ZIP / Postal Code Phone Number(Required)Message PhoneEmail Address(Required) Type of Housing(Required) Own Rent How many people live in your home ?(Required)12345678Do you receive income?(Required)Earned or unearned income Yes No Income Types Wage/Salaries SSI Benefits TANF GA 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 No 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.Applicant No Income Declaration(Required) I do hereby declare that I have received no income for the months ofLIHEAP 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. October November December January February March April May June July August September Select AllI 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 SignaturePlease sign if you have no income. Household Member 2Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H2 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child SUpport Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 3Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H3- Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 4Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H4 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 5Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H5 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 6Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H6 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 7Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H7 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly Amount Received?Household Member 8Name(Required) First Last Suffix Date of Birth(Required) MM slash DD slash YYYY SSI Number(Required)Relationship to HOH(Required)Significant OtherChildParentGrandchildNiece/NephewOther Family MemberGender(Required) Female Male Prefer not to answer Is this person disabled?(Required) Yes No H8 - Does this person receive income?(Required)Earned or unearned income Yes No Income Types(Required) Wage/Salaries SSI Benefits TANF GA Per Capita Payments Child Support Veterans Benefits Other How Often? Weekly Bi-Weekly Twice a Monthly Monthly AmountRequired DocumentsUpload 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 Select files Max. file size: 50 MB, Max. files: 10. Landlord StatementThis 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 SignatureZERO INCOME STATEMENTCERTIFICATIONI 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 informationAuthorization to Vendors(Required) I authorize the following Vendors to release my account information to the Lower Elwha Klallam Tribe’s Social Services Department for the purpose of providing energy assistance services for the current program year 10/1/2022 to 09/30/2023Landlord Name(Required) Electrical Utility Vendor Name(Required) HiddenWater Utility Vendor Name CERTIFICATIONPLEASE 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.
