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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

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Applications received June 1 – September 30:

If application is completed after May 31, indicate what you are applying for.

Responsibilities, Right to Appeal, and Nondiscrimination Policy:

The county social service office representative should briefly give the applicant a verbal explanation of his responsibilities, rights to appeal and should draw his attention to the written statement of his rights to appeal which will be mailed with his "Notice of Action."

Certification and Authorization to Release Information:

The county social service office should draw the attention of the applicant to the certification statement whenever there is a face-to-face or telephone contact. When the application is received in the mail, and there is any indication that the applicant may not understand the full implication of his responsibilities as stated in the certification statement, the county worker should contact the applicant and discuss the applicant responsibilities with him.

This does not include confidential protected health information. This statement was added because this release does not cover medical information that LIHEAP must request. SFN 1059 must be used to receive medical information.

Signature:

The application must be signed by a member of the household before the application can be