Page 5

Louisiana LIHEAP Service Delivery Guide

5 | P a g e

T a b l e o f C o n t e n t s

APPENDICES: LIHEAP FORMS A. Assurance 16 (Client Education) Annual Proposal B. Format for LIHEAP Applicant Files C. Sample Appeal Decision Letter D. LIHEAP Application Required Documents Form E. Income Inclusions and Exclusions Chart F. Verification of Employment (VOE) G. Self-Employment Self Certification Form H. Income Determination Worksheet I. Zero Income Statement Form J. Zero Income Supplemental Sheet K. Statement of Contributions L. LIHEAP Landlord Verification Form for Utilities Included in Rent M. Prepaid Utility Calculation Worksheet N. LIHEAP Crisis Assistance Form O. LIHEAP Assurance 16 (Client Assistance) Household Tracking Report P. LIHEAP Vendor (Client Assistance) Refund Report Q. Suspected Fraud Incident Report Form R. Witness Narrative Report Form