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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
Emergency Assistance Needed The household will fill in the services that are needed.
Name Of Company That Fuel Is Purchased From Who do they receive fuel from.
Name On Account, Account Number Household should list whose name is on the account and an account number if there is one. If there is not account number, "none" should be written.
Dollar Amount Of Emergency Assistance You Are Applying For LIHEAP needs to know exactly how much the household needs to take care of the emergency only.
How Much Have You Paid On Your Energy Bills In The Last 6 Months? Household needs to tell LIHEAP this because it may be a determining factor whether they receive emergency assistance or not.
List The Reasons You Are Applying For Emergency Assistance Allow the household to explain what happened that caused the emergency. This perception of the causes can be a starting point for later discussion regarding an "Action Plan" (SFN 11), if appropriate.
Household's Efforts To Resolve Crisis (Next Two Lines) Have the household describe what he/she has done to handle the crisis, especially any contacts with the supplier.
Plan Household should describe in his/her own words what can be done to prevent future crisis. This will be helpful later in developing an "Action Plan" (SFN 11).