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APPENDIX N Effective: April 1, 2026

Low-Income Home Energy Assistance Program (LIHEAP) Crisis Assistance Form Provider Name:

Applicant Name:

Applicant Last 4 SSN: Number in Household:

Application Date: Application Time:

AM PM Crisis situation is: (Circle One) Life-threatening Non-life-threatening 1. Energy service interrupted or lacks heating/cooling: (Circle all that apply) o Threatened interruption o Actual interruption o Lack of heating source o Lack of cooling source 2. Health and/or medical safety risk: (Circle one) Yes No  Risk must be documented. Types of documentation include, but are not limited to, medical reports, caseworker reports and disconnect notices during times of extreme temperature.

3. Assistance Needed to Resolve the Crisis: (Check one) ___Bill Payment Total $_____ = (LIHEAP ______; Client/3rd party______) ___Equipment Repair or Replacement Estimated Cost: $

Circle one: Heating System Repair Heating System Replacement Cooling System Repair Cooling System Replacement 4. Description of Crisis Situation: _____________________________________________________________________ ____________________________________________________________________________ 5. Delivery of Services: Life-threatening (18 hours): Date Time

Non-life-threatening (48 hours): Date Time

Authorized Provider Signature Date