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pg. 3 FORMS LIHEAP FORMS

Form Number Form Name Location LIHEAP-1 Application For Financial Help to Heat or Cool Your Home EA Web Site Authorization For Release of Information FSD Form LIHEAP-1B Information Request FSD Form LIHEAP-1C Low Income Interview Guide FSD Form EA-1E Energy Assistance Landlord-Renter Documentation Request One Form LIHEAP-3 Employee Wage Documentation Report FSD Form EA-6 Energy Assistance Eligibility Notice: Eligible Eligible – Natural Gas Customer Ineligible AFP produced by IT Denial Letter Energy Assistance Notice of Denial FSD Form EA-7 Energy Assistance Payment Notice AFP produced by IT LIHEAP-8 Energy Assistance Claims and Restitution FSD Form EA-10 Energy Assistance Check Cancellation Notice One Form EA-11 Energy Assistance Check Reissuance Request One Form Fax-Scan DCN Update Coversheet Word Document IM-87 Application for State Hearing FSD Form IM-214 Affidavit for Replacement Check FSD Form IM-215 Affidavit of Forgery FSD Form IM-145 Change Report FSD Form

SECURITY FORMS

Form Number Form Name Location Security Forms Instructions Word Document Community Initiative Unit Access Request Word Document DSS Confidentiality Statement PDF Document