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

needed to assist in the income verification process.

Do you currently receive or have you recently applied For (Check X, if yes) Medical Assistance, General Assistance, SNAP, Child Care Assistance Housing Assistance, TANF.

Disability:

This question is also for reporting and administrative purposes only and cannot be required if the applicant objects to answering it. The definition of handicapped or disabled is included in the definitions section of this manual. (See 05-05)

Income:

Check "yes" or "no" to each type of income, enter the amount of income, and indicate whether it is received weekly, monthly, quarterly, or annually.

It is not necessary to identify which members of the household have income; however, the income from all members of the household must be included in this section.

Expenses

Medical:

Check "yes" or "no" to any medical expenses incurred since the previous June 1. Proof of the expenses must be provided. See 25-05-05-05 for the complete list of allowable expenses.