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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 62, Emergency Assistance Application/Assessment 415-65-30 (Revised 10/1/18 ML #3533) View Archives

SFN 62 is to be used by LIHEAP and for referral to Energy Share of North Dakota. If the customer needs assistance from Energy Share, the LIHEAP worker should make a copy of the form and send it to Energy Share.

There are two sections of the form: 1) Application and 2) Agency Use Only. The "APPLICATION" section is to be completed by the household. The "Agency Use Only" section is completed by the worker.

The worker should check for completeness. Incomplete applications are not acceptable. The worker should assist the household to complete the application. No uncompleted applications or unsigned applications will be entered into the LIHEAP system.

"APPLICATION"

Identification The name and social security number should be the same as the head of household used for the Heating Assistance Program.

County: Enter the county of residence.

Address: Enter the mailing address.

Phone: Enter a number at which the family can be reached.

Ages: Enter the ages of all the household members. The head of household should be entered first.