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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

SFN 530, Eligibility and Benefit Worksheet 415-65-10 (Revised 10/1/17 ML #3512) View Archives

This form is only available electronically via E-Forms.

It is not necessary to complete Form 530 "Eligibility and Benefit Worksheet" for each month of the LIHEAP heating season prior to the month of application. However, it is necessary to establish and verify the income available to the household during those months if a reimbursement or back bill incurred in an earlier month is to be paid by LIHEAP.

The income eligibility information must be entered on the Form 530 for the month of application as in the following example for a family of four (be sure to subtract deductions before deciding eligibility): Prior months eligibility (wage stubs on file): October: Earnings of $1600/mo. x 12 x 73% = $14,016 - $1,200 = $12,816 - ineligible November: Earnings of $1500/mo. x 12 x 73% = $13,140 - $1,200 = $11,940 - eligible