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APPENDICES

Appendix A Crisis Assistance Checklist Appendix B LIHEAP-124 Form - Physician/Nurse Medical Statement Appendix C LIHEAP-102 – Declaration of Household Income Appendix D Payment Assistance Chart Appendix E LIHEAP-108 Form - Home Energy Supplier Agreement Appendix F Wood Dealer Checklist

Appendix G LIHEAP-117 Form - Invoice (Wood/Coal/Kerosene) Appendix H FACSPro LIHEAP Application Appendix I LIHEAP 101-A Form - Client Home Energy Data Request Waiver Appendix J LIHEAP-104 Form - Summarized Eligibility Requirements Appendix K LIHEAP-106 Form - Hearing Notice Appendix L LIHEAP-107 Form - Fair Administrative Hearing Appendix M LIHEAP-119 Form - Erroneous Payment Review/Report Appendix N LIHEAP-120 Form - Repayment Agreement Appendix O Sample Denial Letter Appendix P Vendor Refund Form