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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 1540, Annualizing Worksheet 415-65-15-05 (Revised 10/1/12 ML #3343) View Archives

The annualizing worksheet is on the back side of SFN 1540. Each month of the heating season has a space on the form to enter and annualize each source of income received, indicate how it was verified, and enter the amount/unit monthly, weekly, etc.) received. Multiply the amount/unit times the appropriate annualizing figure as described in 415-25-05-15.

This annualized income is then multiplied by 73%, ONLY IF IT IS EARNED INCOME, to arrive at the annualized amount for that source of income. Once each source of income for the month has been annualized, total them and enter the result as the total for that month.

Repeat this process for each month prior to the month of application backwards to October.

Note: Total deductions from Line E, SFN 530, must be subtracted from each month’s annualized income before eligibility for the month can be established.

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