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APPENDIX R SAMPLING REVIEW CHECKLIST

Minimum Information each agency (grantee) must collect, verify, copy, and retain. CHECK IF APPLICABLE Issues Found/Date Issue Resolved by Grantee Copy of MEAP Self-Sufficiency Plan attached?

Intake Worker Signature

Application Received Date

Client/Household Signature

Client/Household Signature Date

Full Name for all household members

Address

City and Zip Code

MDHHS Case Number

County

SER Decision Notice (or other proof of SER eligibility)

Household received energy assistance from another agency or through a provider-sponsored program since October 1?

Document the energy type

Copy of the utility bill with past due balance

Document the utility name

Document the utility account number

Document the utility amount to be paid

Deliverable Fuels - records kept of metered delivery notification

Deliverable Fuels - records kept of amount of deliverable fuel provided

Deliverable Fuels - records kept of amount of deliverable fuel already on hand to show need. (Tank at 25% or less.)

Documentation for Direct Energy Payments • Submitted with FSR o Spreadsheet with names of all the clients who are receiving assistance (if the check or EFT is for more than one person) o Check request form o Cleared check or EFT paperwork o Bank statement the check or EFT cleared on o General Ledger o Additionally, for APP payment support:  APP Credit File  APP Monthly Enrollment File • On File o SER Decision Notice o Quote (for deliverable fuel)  Quote may be a verbal estimate over the phone, but the following information is required: • Date • Client name (and name on account if different) and case number • Amount needed to resolve the emergency • Any other pertinent account information • Name of the person at the utility company who provided the information • Signature of the grantee staff person obtaining the information o Grantee letter committing to pay specified amount o Invoice or screen shot of amount paid (from Energy Assistance Portal)