Page 334

Low Income Home Energy Assistance Program Division 10 Service 415 Program 415 Chapters 05 - 65 North Dakota Department of Health and Human Services

SFN 529, Application 415-65-05 (Revised 10/1/19 ML #3557) View Archives

This form is available through the Department of Human Services and may also be obtained electronically via E-Forms (1136kb pdf).

For_Office_Use_Only

Date Received:

Enter the date a completed and signed application is received in the county social service office. This is the date which will later be entered on the computer "Household Data" screen as 'Date of Application.’

Case Number:

Head of Household:

The use of a case number for LIHEAP is NOT mandatory. However, if no case number is used, the two-digit county identification number MUST still be entered on the computer "Household Data" screen. The case number must include at the beginning the two-digit identification number of the county.

Name:

Enter the name of the head of the household.

Social Security #:

Enter the Social Security number of the head of the household. If the applicant has no social security number, leave it blank and request