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APPENDIX I

LIHEAP ZERO INCOME STATEMENT FORM

Date:

I, (Full Name) , (SSN)

do hereby certify that I am unemployed and have no income for the following reason: (check appropriate reason(s))

Laid off. Enter month and year of last date worked

The job I had was seasonal and has ended

I am unable to find employment

I have been or am (circle one) sick / injured and unable to return to work.

I expect to return to work by (month/year)

I have small children and no one to care for them except me.

My only source of income is from

I am no longer eligible for Unemployment Benefits.

I receive assistance from the La. Dept. of Social Services: (circle all that apply) Food Stamps, TANF funds, OTHER:

Other (Please use the space below to write any conditions that are not covered above.)

I understand that if I knowingly give incomplete, inaccurate, or incorrect information I am subject to criminal prosecution under Title 18 of the U.S. Code.

Signature:

Client Signature

Agency Representative

NOTE: THIS FORM SHOULD BE COMPLETED FOR ALL ADULT HOUSEHOLD MEMBERS 18 YEARS OF AGE OR OLDER WHO REPORT ZERO INCOME. Effective: April 1, 2026