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APPENDICES

Appendix A Crisis Assistance Checklist

Appendix B LIHEAP-124 Form - Physician/Nurse Medical Statement

Appendix C LIHEAP-102 Form - 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