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LIHEAP MANUAL JANUARY 2022 86

30. Account Number

31. Vendor Name

31a. Applicant's Signature

32. Release of Information /Approved

33. Disapproved

IF THEN The home energy supplier uses account numbers Enter the proper account number for the household The home energy supplier uses names Enter the name under which the account is listed The home energy supplier (vendor code) is 999 Enter the proper account number under which the application was registered if applicable. If not, leave blank.

- enter the proper name of the applicant's home energy supplier exactly as it is listed on the Approved Home Energy Suppliers Vendor List. - enter the name of the person the benefit is being given as a 999.

- the applicant must read or have read to him/her this section and must sign the application in the space provided. If the applicant cannot write, have the applicant make an "X", then the worker must write in the name of the applicant.

- If the application signs the LIHEAP Authorization for Release of General and/or Confidential Information enter an X on the Accept line.

- If the applicant declines, enter an X on the decline line.

- if this application is approved, enter an X in the box.

- If the household is determined to be ineligible for assistance, check this box and enter the reason for the denial on the line provided.