Page 87
APPENDIX D Effective: April 1, 2026
LIHEAP APPLICATION REQUIRED DOCUMENTS FORM
Provider:
Applicant:
Date of Application:
Thank you for applying for the Low Income Home Energy Assistance Program (LIHEAP). In order to complete your application, you will need to bring in the documents checked below within the next ten (10) business days. If these documents are not received by , your application will be determined incomplete and you will need to re-apply.
U.S. State Issued Driver’s License or U.S. Government Issued Photo ID (All household members age 18 and up)
Social Security Card (All household members) Proof of Income (All household members)
Disconnect Documentation (If Applicable) Utility Bill(s) dated within the past 30 days
Verification of Utility Allowance (If Applicable) _____ Verification of Disability (If Applicable) Other: Other:
Proof of Income may consist of one or more of the following:
All Check Stubs within the previous 30 days
Insurance or annuity payments W-2 Tax withholding statement
Dividends & Interest Statement Most recent Tax Return (If Self-Employed)
Net rent income Documentation of Unemployment Benefits
Royalties Workers Compensation Benefits
Periodic Receipts from estates or trusts Alimony
Net game winnings Railroad Retirement
Regular Contributions that are not loans to be Repaid
Veterans Benefits
Bank Statements Private Pensions
Social Security Award Letter Government Employee Pensions SSI Award Letter
Other: Other:
The Agency reserves the right to request additional documents or clarification for any reason deemed necessary.
Signatures:
Applicant Date
Agency Representative Date