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APPENDIX J Effective: April 1, 2026 LIHEAP ZERO INCOME SUPPLEMENTAL SHEET

APPLICANT NAME:

MONTHLY EXPENSES MONTHLY INCOME

SECTION 1: HOUSEHOLD MONTHLY EXPENSES SECTION 3: MONTHLY INCOME

SECTION 2: VEHICLE MONTHLY EXPENSES SECTION 4: EXEMPT INCOME

FOOD STAMPS AFDC CHILD SUPPORT OTHER INCOME TOTAL EXEMPT INCOME

INSTRUCTIONS: 1. ENTER EXPENSES AMOUNT REPORTED BY APPLICANT IN SECTION 1 AND 2. 2. ENTER INCOME AMOUNTS IN SECTION 3 AND 4. 3. THE INTAKE WOKER MUST ASK APPLICANT FOR WRITTEN EXPLANATION OF INCOME SOURCES, IF ANY. (FOR EXAMPLE, ASK APPLICANT HOW THEIR EXPENSES ARE BEING PAID. THE INTAKE WORKER MUST DOCUMENT THE APPLICANT’S FILE WITH THIS INFORMATION UNDER SECTION 3 AND 4.)

*NOTE: ALL REGULAR CONTRIBUTIONS RECEIVED FROM FAMILY AND/OR FRIENDS MUST BE DOCUMENTED ON THE STATEMENT OF CONTRIBUTIONS FORM, WHICH IS TO BE FILLED OUT, SIGNED AND DATED BY THE PERSON GIVING THE CONTRIBUTION.

I CERTIFY TO THE BEST OF MY KNOWLEDGE INFORMATION PRESENTED ABOVE IS ACCURATE. APPLICANT’S SIGNATURE:

DATE:

AGENCY REPRESENTATIVE’S SIGNATURE:

DATE:

RENT/MORTAGE FOOD PURCHASES AVG. ELECTRIC BILL AVG. GAS BILL AVG. WATER BILL SEWER/GARBAGE HOME TELEPHONE CELL PHONE CABLE/SATELLITE CLOTHING EXPENSES SCHOOL EXPENSES MEDICAL EXPENSES (NOT MEDICINE) PRESCRIPTION EXP TOTAL HOUSEHOLD SELF EMPLOYMENT WAGES SSA SSI VETERANS PENSION UNEMPLOYMENT WORKMAN’S COMP RENTAL INCOME ALIMONY TANF CASH ASSISTANCE REGULAR CONTRIBUTIONS *FAMILY *FRIENDS OTHER TOTAL INCOME CAR NOTE AUTO INSURANCE AVG. FUEL COST TOTAL VEHICLE TOTAL HOUSEHOLD EXP TOTAL VEHICLE EXPENSES OTHER (IF ANY) TOTAL EXPENSES