Page 85

LIHEAP MANUAL JANUARY 2022 85

23. Monthly Income

24. Income Level

25. Energy Crisis Intervention Authorization

26. Main Heating Fuel Type

27. Amount of Assistance Authorized

28. Vendor Code

29. Account Name

- enter here the total monthly income for the entire household.

- using the Income Worksheet information and the Income Level Chart, enter here the one digit income level according to household size and gross income code to be used in calculating the amount of assistance to be provided to this household.

- enter 2 (Prevention of Energy Source) or a 3 (Restoration of Energy Source) if completing a crisis application. Leave blank. Do not write 0, N/A, or any other notation if not.

- enter the appropriate letter to indicate the Main Heating Source/Fuel Type in the household receiving this benefit

- From the appropriate Payment Assistance Schedule, enter the amount of assistance for which this household is authorized. Example: 350

IF THEN The applicant uses as a primary home heating source a supplier who has signed a Home Energy Supplier's Agreement enter the supplier's three-digit code found on the approved Vendor List Enter the supplier's three-digit code found on the approved Vendor List. The applicant uses a home energy supplier that has not signed an Agreement Enter 999 as the vendor code

- enter the name on the account in which the benefit is being paid to. - enter the name of the applicant if the home energy supplier is not listed on the utility bill or other means of documentation is accepted as proof of bill (ex. Statement from wood provider).